JOURNAL OF THE INDIAN ACADEMY OF GERIATRICS n Info/Articles/JOURNAL OF... · Journal of The Indian Academy of Geriatrics, Vol. 3, No. 4, December, 2007 and emergency healthcare for

JOURNAL OF THE INDIAN ACADEMY OF GERIATRICSOfficial Publication of The Indian Academy of Geriatrics

December 2007 Vol. 3, No. 4

C O N T E N T S

Editorial Action BeginsMathur A ........................................................................................... 133

Original Articles Culprit Effect of Altered Total Antioxidant Statusand Lipid Peroxidation Mediated Electrolyte Imbalanceon AgingSaxena R, Lal A M ............................................................................ 137

Life-Satisfaction Among Rural Elderly Females in Chittoor District

Swarnalatha N ................................................................................. 145

Review Articles Old Age and Frailty: Genesis and ManagementGoel A, Dey A B ............................................................................ 150

Delirium in ElderlySingh R, Coutin I B, Kejriwal K ....................................................... 154

Current Perspective Health Economics For GeriatricsKishore J, Ingle GK ........................................................................... 160

Book Review National Health Programmes of India: National Policiesand Legislations Related to Health ....................................................... 165

Journal Scan ......................................................................................................... 166

Announcements ......................................................................................................... 153

JOURNAL OF THE INDIAN ACADEMY OF GERIATRICSPeer-reviewed, Official Publication of the Indian Academy of Geriatrics

Journal of The Indian Academy ofGeriatrics is published quarterly (inMarch, June, September andDecember).

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PUBLISHERDr Arvind Mathurfor and on behalf ofThe Indian Academy of Geriatrics

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Editorial

The increasing number of older people in Indiansociety has been well perceived. Proportion of olderpeople is growing faster than of any other age group.While population ageing is a success story ofsocioeconomic development and good public healthpractice, it has also lead to economic and social crisisdue to crumbling support system, with increaseddemand for health and welfare services.

Responding to the needs of the ever-increasingnumber of older people, the Government of India (GOI)announced the National Policy on Older Persons(NPOP) in 1999 with Ministry of Social Justice andEmpowerment, as the nodal ministry. As far as thehealth care of the elderly is concerned, with fundingsupport from GOI-WHO collaborative programmetrainings of medical specialists, medical officers andhealth care personnel at the grass root level have beencarried out. IEC and training material was also developedunder this programme. Yet much more remains to beaccomplished in our country.

Though research in geriatrics in past decades hasprovided insight into various aspects of the health statusof the older people, the studies on the health needsand health problems of the elderly are sparse in ourcountry. Various studies have been carried out at state/regional levels in respect of health problems of theelderly, there has never been a uniform study carriedout in different parts of the country at the same timeadopting similar parameters. Therefore to generatebaseline epidemiological data concerning healthproblems of the elderly, it was felt by the DirectorateGeneral of Health Services/ Ministry of Health andFamily Welfare to get a multicentric study conductedat ten different geographical locations in the country.This study supported under GOI-WHO collaborativeprogramme was a laudable attempt in the field ofgeriatrics. This study was a cross-sectional communitybased study of elderly population aged 60 years andabove carried out at ten centers i.e. Chandigarh, Delhi,Shimla, Gauhati, Raipur, Jodhpur, Pune, Trivandrum,Chennai, and Vellore. These ten different centers werechosen across the country with a view to provideregional representation in the data generated.

Action BeginsMathur A

Medical colleges in these centers were given theresponsibility to gather information based on a standardproforma developed for this purpose. Using structuredquestionnaire 1000 subjects with equal number fromrural and urban area were studied at each center. Thevariables studied were demographic data, perceivedhealth status, health related expectations and needs,health care facilities utilization, clinical examination bya nurse and doctor as well as laboratory investigationslike hemoglobin, routine urine examination, fastingblood glucose, serum cholesterol and anelectrocardiogram. Poor Vision (45.4%), Hypertension( 38.2%), Arthritis ( 36.1%), Bowel complaints ( 31.6%),Depression ( 23.6%), Difficulty in Hearing ( 20.5%),Weight Loss (19.6%), Anaemia (16.8%), Urinarycomplaints (13.4%), Diabetes (13.3%), Fall ( 8.7%),IHD ( 7.7%), Asthma ( 6.6%), COPD ( 4.8%), andTuberculosis (3.1%) were the common health problemshighlighted by the study.1

India is a vast country and ten centers still maynot reflect correct picture. Survey has been crosssectional with its limitations however the strength ofthe study has been a good sample size (n=10035).It is first of its kind in India and it has covered allimportant health related issues of elderly required forplanning of health programme.

The elderly (people above the age of 60 years)comprise 7.5 percent of India’s total population, andmaking health care available and accessible to themis one of the health priorities of the country. Evidencebase generated by the multicentric study will help inplanning of health service provision for elderly in ourcountry. The study proposes a simple sustainable andeconomical health care delivery system for elderly atcommunity level with existing health care services.

It is commendable that there is a strong thruston health in eleventh five year plan. The 11th Five YearPlan aims at inclusive growth by introducing SarvaSwasthya Abhiyan that will find solutions for strengtheningthe health services and focus on neglected areas andgroups. The 11th Plan envisages a range of servicesunder the National Programme for Older Persons toimprove the access to promotive, preventive, curative

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Journal of The Indian Academy of Geriatrics, Vol. 3, No. 4, December, 2007

and emergency healthcare for older people.

A home health service, entailing home visits todetect health problems, and as a psychological supportby health personnel sensitized on such issues will beintroduced. Also, a community-based health centre forthe aged for educational and preventive activity will beinitiated. This will be integrated with the NRHM(National Rural Health Mission) and an allocation madespecifically for geriatric care. The Accredited SocialHealth Activist (ASHA) will be trained in geriatric careand the out-patient medical service, which serves asthe base for home health service, will be enhanced.

Finally, an improved hospital-based support service,focusing on their healthcare needs, will also be made

for widows and a few centres on geriatric health willfocus only on elderly women. The government willdevelop two National Institutes for Ageing, one in theNorth and another in South of India.2

At last real action has commenced, to implementthe plans for improving health of our elderly.

References1. Srivastava RK. Multicentric study to establish epidemiological

data on health problems in elderly: a Govt. of India and WHOcollaboration programme. Ministry of Health & Family Welfare,Government of India 2007.

2. h t t p : / / w w w . t h e h i n d u . c o m / 2 0 0 7 / 1 2 / 2 7 / s t o r i e s /2007122759331100.htm

Original Article

Culprit Effect of Altered Total Antioxidant Statusand Lipid Peroxidation Mediated ElectrolyteImbalance on AgingSaxena R*, Lal A M**

Abstract

Background: Cellular damage by reactive oxygen species including those associated with lipid peroxidationare now accepted to be related with a variety of pathological events including aging and its consequentsequelae. Among various alterations, electrolyte imbalance leading to disturbance in normal homeostasishas been found to be a major event in the progression of aging. It is conceivable that alteration in plasmaantioxidant reserve in association with lipid peroxidation may have a crucial role in aging process as well.However, there is a paucity of satisfactory explanation regarding the alteration in non-enzymic antioxidant statusand lipid peroxidation mediated electrolyte imbalance with increase in age.

Aim: The objectives of present study were to ascertain the plasma levels of total antioxidant activity (TAA),non-enzymic antioxidants, malionaldehyde (MDA) and serum minerals in the subjects of different age groupsand to determine their cumulative effect in the progression of aging process.

Material and Methods: In the present study, 120 healthy subjects were selected and non enzymatic antioxidantreserves (TAA, Vitamin C, E & A, uric acid and albumin), malionaldehyde and serum mineral ( Na

+, K

+, Mg

2+

and Ca2+

) levels were measured using standard methods. Out of 120 subjects, 80 healthy individuals werecategorized into two groups: group I (40-55 years) and group II (? 56 years) and statistically compared it withthat of 40 younger controls (20-30 years) by using student’s t-test.

Result: Plasma TAA, vitamin C, E & A, and albumin levels were significantly low (p<0.05, p<0.001) in groupI and II as compared to healthy controls whereas erythrocyte MDA level was increased significantly (p<0.05)in both the groups. On the other hand, plasma uric acid level and serum sodium levels were increasedsignificantly (p<0.05) only in group II subjects whereas serum magnesium, potassium and calcium levelsrevealed significantly low values (p<0.05 ) in group II subjects as compared to healthy controls. However,these levels were altered insignificantly (p<0.1) in group I subjects.

Conclusion: Our findings indicate that alteration in TAA, non-enzymic antioxidants and serum minerals levelsdue to augmented oxidative stress contributes aging process not only by inducing bio-molecular deteriorationbut also by disturbing haemostatic control via electrolyte imbalance. Therefore, maintenance of healthyantioxidant status and electrolyte balance by consuming diet rich in antioxidant vitamins, proteins and mineralswith increasing age could be effective in reducing aging and its related complications.

Keywords: Total antioxidant activity, lipid peroxidation, aging, ? -tocopherol, electrolyte imbalance. (Abbreviations:TAA - Total Antioxidant Activity; MDA – Malionaldehyde; Na

+ - Sodium; K

+ - Potassium; Ca

2+ - Calcium; Mg

2+

- Magnesium)(Journal of The Indian Academy of Geriatrics, 2007;3 137-144)

*Dr Rahul SaxenaResident, Department of Biochemistry,M L N Medical College, Allahabad.**Dr A M LalProfessor, Department of Biochemistry, AAI-DU, Allahabad.

Address for CorrespondenceDr Rahul Saxena C/o Dr Geeta Jaiswal,234 Attarsuia Allahabad.email: [email protected]

IntroductionToday’s concept of oxygen toxicity and antioxidant

defence system is not restricted only to some diseasesbut it has now been receiving much attention towardssolving the unanswered question related to agingprocess. Oxidative stress ensues when large amountof reactive oxygen species are produced in the cells,that can evade or overwhelm the antioxidant protectivemechanisms of cells and tissues, and produce majorinterrelated impaired cell metabolism including DNA

137

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strand breakage, rise in intracellular free Ca2+, damageto membrane ion transporters and other specificproteins leading to cell death.1 Prime target to freeradicals attack are the polyunsaturated fatty acids inthe membrane lipids, causing lipid peroxidation, whichhas been found to be a major event in the productionof pathophysiological alterations in elderly.2 Lipid peroxide(malionaldehyde) is most abundant among the reactivealdehydes derived from lipid peroxidation. It has beensuggested that binding to these aldehydes to membraneprotein may alter their function, tonicity, permeability,rigidity and integrity, and thereby may induce culpriteffect on electrolyte imbalance leading to the progressionof aging progress.3 However conversely, activation ofion pumps under the influence of free radicals productionto normalize perturbed ionic homeostasis has beendocumented.4 The important elements responsible forelectrolyte balance, pH and function of enzymesinclude sodium, potassium, magnesium and calcium,and their optimal concentration for proper physiologicalactivities of the cell is maintained by ion channels.Interestingly, Garg and Sanchette have well elucidatedthe role of various ion channels in CVD, CNS, tastesensation, skeletal muscle, renal, respiratory,pancreatic, erectile and platelet function.5 Inactivationof these ion channels may produce physical andfunctional disability with age.

These free radicals are efficiently removed byantioxidant defence system, which includes antioxidantenzymes and antioxidants. Total antioxidant activity(TAA) including co-operative action of other widelyrecognized non enzymatic antioxidants such as vitaminC, E, A, uric acid and albumin, may have a significantrole in the physiochemical alterations during aging andhave received much attention in preventing age relatedcomplications. Vitamin C, an exogenous water solubleantioxidant, functions as primary defense against freeradicals in plasma. It plays a key role in protectingplasma lipids against peroxidation, collagen synthesis,wound healing and improving vascular endotheliumdependent vasodilation.6 Vitamin E, mainly ? -tocopherol,is the most potent lipid soluble chain breaking antioxidantwhich has been theorized to extend life span, enhancecell mediated immunity in elderly people and preventage related functional decline and diseases.7

? -tocopherol quenches and reacts with superoxideanion, hydroxyl and peroxyl radicals to protect againstoxidative stress mediated biomolecules and membranedamage via lipid peroxidation.6 In addition, ? - carotenemainly carried on LDL particle, is also an efficient fat

soluble antioxidant that can quench singlet oxygen,inhibit nitric oxide mediated oxidation and responsiblefor immune response, epithelial growth and repair.8

Although previous experimental and epidemiologicalstudies have suggested a modest benefit of theseantioxidant vitamins in reducing the electrolyte imbalanceand age related deteriorations, in general the evidencesare sparse and unconvincing which needs furtherinvestigation regarding the role of these non-enzymicantioxidant vitamins in aging.7,9

Similarly, there has been renewed debate aboutthe nature of association between plasma uric acid andage related complications. Ames et al. reported thaturic acid, an end product of purine metabolism, is aneffective antioxidant in plasma as it scavengessuperoxide radical, protects erythrocyte againstperoxidative damage and free radical attack.10

Conversely, its relation with circulating inflammatorymarkers, vascular injury and endothelium are welldocumented.11 Moreover, plasma proteins are majorcellular, structural and functional constituents andcontribute antioxidant defenses.12 Several investigatorsalso observed that the accumulation of oxidized proteinoccurs in a number of tissues during aging and thereby associated with reduced life expectancy.13

Despite these contradictory and limited evidences,there is no conclusive evidence on the total systemicantioxidant activity and other non-enzymic antioxidantsin relation with oxidative stress mediated electrolyteimbalance in subjects. Therefore, the overall objectivesof present study were to ascertain the plasma levelsof TAA, non-enzymatic antioxidant reserves (includingvitamin C, E, A, plasma albumin and uric acid levels),malionaldehyde and serum minerals (Na+, K+, Mg2+

& Ca2+) in subjects of different age groups and todetermine their cumulative effect in the progression ofaging process.

Material and MethodsIn the present study, 120 healthy, non-

supplemented (not taking any additional vitamins orminerals) subjects of both sex (20 males & 20 femalesin each group) and different age groups were includedfrom urban area of Allahabad city after taking theirinformed consent and approval of protocol by ethicscommittee of the college. These subjects were selectedrandomly and categorized into three groups dependingupon age i.e. control group (younger people) whichincluded 40 healthy subjects of age group 20 – 30years, Group I included 40 healthy subjects (middle

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aged people) of age group 40 – 55 years and GroupII included 40 healthy subjects (elderly people) of agegroup 56 years onwards. After taking the demographicinformation, history and limited physical examination,fasting blood samples were collected in plain vial (forserum minerals estimation) and in EDTA vial fromantecubital vein avoiding venostasis from each subjectafter collecting the information of age, sex, height,weight, blood pressure and confirmation of healthystate. Height and weight were measured with subjectbarefoot and light dressed. The body mass index (BMI)was calculated as BMI = weight (Kg) / height (metre2).Obese (BMI > 25), hypertensives (BP >140/90 mmHg)and smokers were excluded from the study.

Samples were processed immediately for plasmaand serum separation. Plasma total antioxidant activitywas estimated spectrophotometricaly by the methodof Koracevic et al.14 Two milliliter of blood sample wascollected in EDTA bottle. Plasma was separatedimmediately by centrifugation and TAA was measured.

This method is based on the principle that thestandardized solution of iron EDTA complex reacts withhydrogen peroxide by a Fenton type of reaction, leadingto the formation of hydroxyl radicals. This reactiveoxygen species degrades benzoate, resulting in therelease of thio barbituric acid reactive substances(TBARS). Antioxidants from the added plasma causesthe suppression of production of TBARS. The reactionis measured spectrophotometrically at 532 nm.

Erythrocyte malionaldehyde (MDA) levels weremeasured as thiobarbituric acid reactive substances,after preparation of hemolysate.14 The heat inducedreaction of malionaldehyde (MDA) with thio barbituricacid (TBA) in the acid solution forms a trimethinecoloured substance, which is measuredspectrophotometrically at 532 nm.

Plasma ascorbic acid levels were estimated byBurtis and Ashwood method.15 Ascorbic acid in plasmawas oxidized by Cu(II) to form dehydroascorbic acidwhich reacts with acidic 2,4–dinitrophenyl hydrazine to

Table 1: Demographic profile of study subjects (n=120) (mean ?SD)

S No Particulars Control group Group I Group II(n=40) (n=40) (n=40)

1 Age (years) 24.5 ? 4.0 46.0 ? 6.0 65.0 ? 8.0

2 M:F ratio 1:1 1:1 1:1

3 Height (meter) 1.57 ? 0.08 1.53 ? 0.05 1.61 ? 0.07

4 Weight (Kg) 54.8 ? 4.6 57.4 ??3.5 61.8 ??2.4

5 B.M.I. (Kg/m2) 22.2 24.5 23.8

6 Systolic blood pressure (mmHg) 102 ? 8.0 110 ??4.8 118 ? 6.3

7 Diastolic blood pressure (mmHg) 74.0 ??3.5 7.6 ? 4.8 70.0 ??5.0

Table 2: Serum electrolyte levels in different age group subjects. mean?SD.

S No Minerals Control group Group I Group II(n=40) (n=40) (n=40)

1 Sodium level (meq/L) 137.0 ? 8.6 148.8 ? 10.7* 165.20 ? 9.6**

2 Potassium level (meq/L) 3.92 ? 0.46 2.72 ? 0.48* 2.49 ??0.50**

3 Magnesium level (mg%) 2.94 ? 0.82 2.63 ? 0.74* 2.11 ??0.56**

4 Calcium level(mg%) 9.41 ? 0.64 8.67 ??0.72* 7.08 ? 0.64**

Where, * p<0.1 : Not-significant, ** p<0.05 : Significant, *** p<0.001 : Highly significant

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form a red bishydrazone, which is measured at 520nm.

Plasma tocopherol levels were estimated byHashim and Schuttringer method.16 Protein in theplasma or serum was precipitated by an equal volumeof absolute ethanol, the whole mixture was subjectedto extraction by an equal volume of n-heptane. ? ,? 1-dipyridyl was added followed by Ferric chloride reagentto the system which produced the color, obtained byEmmeric-Engel procedure. It was measuredspectrophotometrically at 510 nm.

Plasma uric acid levels were estimated byCaraway’s method in which uric acid react withphosphotungstic acid in alkaline medium forming a bluecolor complex which is measured at 700 nm.18

Plasma Vitamin A were measured by Sinhamethod in which vitamin A was extracted from plasmaby using absolute alcohol and heptane. The heptaneextract was kept in one tube and took same volumeof working standard (500 I.U. per 100ml heptane) inanother tube. Both the tubes were placed under a

mercury lamp for three hours. The vitamin was destroyedin these solutions which was measuredspectrophotometrically at 327 nm against water blank.17

Plasma albumin levels were estimatedspectrophotometrically.19 The reaction between albuminand bromocresol green produced change in colour thatwas proportional to the albumin concentration.

Serum electrolytes (Na+ and K+) levels weremeasured by Sinha method by using flame photometerin which test sample was aspirated followed bycalculation of test sample value from calibration curveof standard solution (i.e. NaCl and KCl solution).21

Serum magnesium levels were estimated by Neill andNeely method in which protein free filtrate was treatedwith titan yellow solution.22 A red color complex isformed which is measured at 520 nm. Serum calciumlevels were estimated by Tinder’s method.23 Calciumin an alkaline medium combines with o-cresolphthaleincomplex to form a purple coloured complex which ismeasured at 570 nm. The data from both the studygroup subjects and controls were expressed as mean

Table 3: Plasma Total antioxidant activity (TAA), Malionaldehyde (MDA) and non enzymatic antioxidants levelin different age group subjects. mean?SD

S No Particulars Control group Group I Group II

(n=40) (n=40) (n=40)

1 TAA level(m mol/L) 1.32 ? 0.21 1.04 ? 0.13** 0.89 ? 0.14***

2 Ascorbate level(mg%) 0.78 ? 0.16 0.59 ? 0.10** 0.46 ? 0.08***

3 Tocopherol level (mg%) 1.44 ? 0.42 1.15 ? 0.37** 0.88 ? 0.26***

4 Vitamin A(µgm%) 115.84 ? 22.15 85.36 ? 14.6** 78.42 ? 16.8***

5 Uric acid (mg%) 4.62 ? 1.36 5.2 ? 2.4* 6.9 ? 1.72**

6 Malionaldehyde(µmol MDA/ml) 1.57 ? 0.10 2.16 ? 0.13** 2.38 ? 0.09***

7 Albumin (gm%) 3.8 ? 0.68 3.0 ? 0.24** 2.64 ? 0.37**

Where, * p<0.1 : Not-significant, ** p<0.05 : Significant, *** p<0.001 : Highly significant

Table 4: Correlation coefficient between erythrocyte MDA level and serum electrolyte levels in middle aged andelderly subjects.

Particulars Sodium level Potassium level Magnesium level Calcium level

MDA levels in Group I +0.216* -0.185* -0.282** -0.228**

MDA levels in Group II +0.321** -0.348** -0.421*** -0.529***

* p<0.1 : Not-significant, ** p<0.05 : Significant, *** p<0.001 : Highly significant

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(?SD) and compared by using Student t-test, distributionof probability (p) and linear regression for correlation.

Result In the present study, the mean blood pressure

and anthropometric indices of the study group subjectsare depicted in Table 1. The observations made revealedsignificant changes in plasma TAA, erythrocytemalionaldehyde, non-enzymatic antioxidant status (Table2), and serum minerals levels (Table 3) of different agegroup subjects. The correlation coefficient betweenserum minerals and erythrocyte malionaldehyde levelsis represented in Table 4. Plasma total antioxidantactivity was found to be significantly low (p<0.05 &p<0.001) in both the study groups i.e. 21.0% and 32.5%low as compared to controls. Similarly, plasma ascorbatelevels in both the study group subjects were 24.3%and 41.02% low as compared to controls and statisticallythese values were highly significant. Marked reductionwas observed in plasma tocopherol levels (29.4% and38.8% low), plasma Vitamin A levels (22.0% and 28.9%low) and plasma albumin levels (26.0% and 35.6% low)in both the study group subjects i.e. Group I and GroupII respectively as compared to healthy controls. Moreover,erythrocyte MDA levels were 25.3% and 42.0% highin Group I and Group II respectively as compared tohealthy controls. Interestingly, MDA levels were foundto be inversely related with serum K+, Mg2+ and Ca2+

levels and directly related with serum Na+ levels ofdifferent age group subjects. Significant increase inplasma uric acid and serum sodium levels wereobserved only in Group II (p<0.05) subjects whereasin Group I subjects, plasma uric acid and serumelectrolyte levels were not significantly altered (p<0.1).Although these levels reveal continuous variation withincrease in age, statistically these values were notstatistically significant (i.e. on comparing Group I andGroup II).

Discussion Aging is a universal and inevitable, normal

biological phenomenon associated with physiologicalchanges that lead to functional deterioration of organswith an increased susceptibility to disease.24 The freeradical theory of aging also states that aging is a resultof cumulative damage incurred by free radicalreactions.25 Moreover, the contributory effect ofelectrolyte imbalance and oxidative stress in agingprocess has attracted attention among epidemiologists,clinicians and experimental researchers. Themechanisms whereby free radicals may exert cytotoxic

effect related to aging process include damage to cellmembrane via lipid peroxidation, ion transporters andelectrolyte imbalance. Lipid peroxidaion is a deleteriousprocess leading to structural modification of complexlipid protein assemblies associated with cellularmalfunction. It has been reported that lipid peroxidationcontributes local membrane destabilization that altersthe proper trafficking of intracellular vesicles,phagocytosis, degranulation, antigen presentation,receptor mediated ligand uptake and many otherprocess leading to age related deterioration.26 In thepresent study, malionaldehyde levels, the mostabundant reactive aldehyde derived from lipidperoxidation, were also found to be significantly highin both middle aged and elderly subjects (p<0.05, Table2) in association with significantly altered levels ofserum minerals (Na+, K+, Mg 2+and Ca2+) in elderlypeople (Table 3) which authenticate the hypothesis thataging is closely associated with lipid peroxidationmediated electrolyte imbalance, destruction in cell,subcellular organelles and biomolecules. Our findingswere in agreement with the findings of Goldberg et al.27

Marked alteration in serum electrolytes due to successiveincrease in lipid peroxidation with increase in bloodpressure has also been observed in our previous studyon hypertensive subjects, between 30 and 65 yearsof age.28 Similarly, Kim and Akera also reported thatfree radical mediated lipid peroxidation causeselectrolyte imbalance not only by injuring Na+-K+-ATPase but also by interfering with normal interactionof membrane pumps (including Na–K–2Cl co-transporterand K+ channel) and production of protein radical inlipid membranes that effects normal ion transport.29

Indeed, these four elements (Na+, K+, Mg 2+ andCa2+) have significant role in maintenance of homeostasisby participating in various physiological activities suchas neuromuscular irritability, nerve conduction, cardiaccontractility, insulin release in response to changes inblood sugar, vascular smooth muscle proliferation,vasodilation, inhibition of free radical formation, in properfunctioning of enzymes which include Na+- K+-ATPase,Ca2+-ATPase, enzymes of carbohydrate and fatty acidmetabolism; cell division, calcification of bones andteeth, in the synthesis of ATP, DNA, RNA and protein;inhibition of platelet aggregation, inhibition of absorptionand transfer of toxins from the intestine into the bloodand in the prevention of development of obesity andhypertension etc.30 - 34 Altered level of these elementsmay induce series of events leading to progressionof aging and irreversible damage to vital organs.

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In addition to electrolyte imbalance and its resultantcomplications, lipid peroxidation initiates a complexcascade that promotes aging effects such asatherosclerotic plaque formation followed by myocardialinfarction, inhibition of NO and prostacyclin synthesis,enhancement of cytosolic free calcium and peripheralvascular resistance leading to hypertension; and leakageof lysosomal hydrolases via breakdown of lysosomalmembrane which cause dystrophic changes in musclefibers leading to weakness of muscles with growingage.24,35,36 However, contradictory report regarding therole of free radicals in activating the ion pumps andhigh MDA levels in younger than in older subjects havebeen documented.4

Electrolyte imbalance and increased production ofMDA may be associated with alteration in antioxidantdefence system. Vitamin C, vitamin E, ? -carotene, uricacid and plasma proteins are major antioxidants. Thesemay confer health benefits and may prevent or postponethe onset of degenerative diseases. Heitzer et alobserved that vitamin C alone can afford protectionagainst the oxidant mediated damage to LDL eventhough it is not lipid soluble.37 Alteration in ascorbatelevels have significant effects on collagen synthesis andthereby affect the strength of bones, tendon, teeth,cartilage and blood vessels with age.38 In the presentstudy, plasma ascorbate levels were found to besignificantly low (p<0.05, p<0.001) and directly relatedwith low minerals level except Na+ level in each studygroup as compared to controls which direct towardsits protective and radical scavenging action in elderly.The present findings were in concordance with findingsof Singh et al. who observed a decreased level ofplasma ascorbate in the population of elderly peopleand suggested that vitamin C supplementation maydelay or postpone age related changes.24 Someadditional possible mechanism through which ascorbatemay affect electrolyte balance and reduce age relateddeterioration include its protective effect on Na+-K+-ATPase against peroxidative damage, synergistic actionto regenerate ? -tocopherol, urate radical repairingaction and by enhancing the availability of NO, a potentvasodilator that reduces the risk of stroke and CVDin older people.6,24,39

Vitamin E, a universal lipophilic, chain breakingantioxidant and a stabilizer of biological membranes,prevents accumulation of free radicals and decreaseslipid peroxidation. It has been well documented that? -tocopherol not only retards LDL oxidation but also

exerts cardioprotective effect (e.g. inhibition of smoothmuscle proliferation, platelet adhesion, aggregation andexpression etc.) and preserves cell mediated immunityin older people.7,40 Depletion of plasma vitamin E levelsas observed in present study (p<0.05, p<0.001) in bothmiddle aged and elderly people is quite similar to thatof Culter and may have a significant effect on electrolyteimbalance during aging not only because of its inabilityto stabilize membrane and limiting lipid peroxidationby scavenging free radicals but also due to reductionin maintaining the body antioxidant reserve andnormalization of superoxide formation.41 Moreover, theassociation of vitamin E deficiency and age relateddisorders such as neurological dysfunction, memoryproblems, cataract formation, maculopathy, myopathiesand diminished erythrocyte life span in elderly havebeen universally accepted.42

Similarly, Vitamin A another fat soluble antioxidant,is believed to play protective role against oxidativedamage as it is specifically carried on LDL particle,quenches singlet oxygen and competitively sparesselenium in metabolic reactions.8,43 Low levels ofplasma vitamin A as observed in present study couldbe explained as it contributes in the prevention of LDLoxidation, in free radical scavenging action in co-operation with other antioxidants and in bone remodelingprocess. Deficiency of vitamin A in the elderly makesthem susceptible to infection and increases the riskof night blindness, xerophthalmia, CVD and other agerelated complications which can be prevented byimproving the blood and LDL-beta carotenestatus.8, 44 Despite data linking antioxidant role ofthese vitamins, pro-oxidant properties of these vitaminsalso play a controversial role.6, 45

Uric acid is another endogenous, preventive andchain breaking antioxidant which contributes about65% of free radical scavenging action, stabilizesascorbate, protects erythrocytes from peroxidativedamage, inhibits free radical damage to DNA andoxidative degradation of hyaluronic acid.10 In thepresent study, plasma uric acid levels were found tobe significantly high (p<0.05) in elderly subjects whileinsignificant elevated levels were observed in middleaged subjects which suggests that body is trying toprotect itself from the deleterious effects of free radicalswith continuous increase in age by increasing uric acidproduction. Olivieri et al also observed elevated levelsof uric acid in elderly people.43 Recently, Ogura et alhave reported a positive correlation of hyperuricemiawith obesity, hypertension and other complications of

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aging.46 In contrast, its role in promoting LDL oxidation,in stimulating granulocyte adherence to the endotheliumand its association with CVD risk and vascular injuryare well documented, which reflects that uric acid hasa dual action in aging process.11, 47

Depletion in total antioxidant activity (TAA) indicatesa disturbance in the antioxidant defence system of thebody, which could be due to decrease in individualantioxidants including plasma albumin levels. In thepresent study, plasma TAA levels decrease continuouslywith increase in age (p<0.05, p<0.001) along withserum minerals levels except Na+, in middle aged andelderly people which clarify the contributory effect ofreduced antioxidant vitamins and plasma albumin levelsdue to augmented oxidative stress that could not becompensated by increase in some other antioxidants.Recently, marked reduction in TAA in elderly subjectsand in Parkinson’s disease have been welldocumented.48,49

About 10-50% of total radical trapping capacityof antioxidants in plasma is contributed by plasmaproteins. Albumin, a major plasma protein contributingsignificantly to TAA, was found to be decreased inmiddle aged and elderly subjects (p<0.05) along withaltered serum minerals level which could not beattributed only to its free radical scavenging action butalso due to co-operative action of various events thatmay contribute aging process such as reduced rateof protein synthesis, reduced absorption of aminoacids, increased rate of protein catabolism, inactivationof ion channels and oxidative modification ofprotein.12, 50 Furthermore, oxidative damage can alsolead to cleavage of polypeptide chain and formation ofcross-linked aggregates as a result the skin, bloodvessels and other tissue become less elastic and stifferwith age that contributes a great extent to the medicalproblems of the old people.38, 51

ConclusionOn the basis of our findings and consistent

findings of previous studies, it can be inferred that freeradical production increases with increase in age anddepletion of total antioxidant status due to their freeradical scavenging action may be an indirect markerof oxidative stress during aging. Moreover, it contributesaging process by inducing bio-molecular deteriorationand by disturbing homeostatic control via lipidperoxidation mediated electrolyte imbalance. In addition,present study also suggests that consumption of diet

rich in antioxidant vitamins (such as vitamin C, E &A), minerals and proteins should be increased withincrease in age which may prevent or postpone theonset of aging and its related complications, not onlyby increasing antioxidant levels and thereby TAAactivity but also by inhibiting lipid peroxidation mediatedelectrolyte imbalance as well.

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2 Yagi K. Assay for serum lipid peroxide level and its clinicalsignificance. In Yai K. Lipid peroxides in biology and medicine.Academic press, London 1982; 233-242.

3 Shoe M, Jackson C, Yu BP. Lipid peroxidation contributesto age related membrane rigidity. Free Rad Bio Med 1995;18:977-984.

4 Sen CK, Kolosova I, Hanninen O, Orlov SN. Inward potassiumtransport system in skeletal muscle derived cells are highlysensitive to oxidant exposure. Free Rad Bio Med 1995; 18:795- 808.

5 Garg MK, Sanchette PC. Ion channels and channelopathy.J Assoc Physicians India 1999; 47 : 436-439.

6 Nishikimi M, Yagi K. Biochemistry and molecular biology ofascorbic acid biosynthesis. (In) Subcellular Biochem, Plenumpress, New York.1996; Vol 25: 17-25.

7 Meydani SN, Meydani M, Blumberg JB, et al. Vitamin Esupplementation and in vivo immune response in healthyelderly subjects: a randomized control trial. JAMA 1997; 277:1380-1386.

8 Fairfield KM, Fletcher RH. Vitamins for chronic diseaseprevention in adults. JAMA India 2003; 2 : 54 – 64.

9 El-Kadiki A, Sutton AJ. Role of multivitamins and mineralsupplements in preventing infections in elderly people:systematic review and meta-analysis of randomized contolledtrials. BMJ 2005; 330: 871 - 874.

10 Ames BN, Cathcort R, Schwiers E et al. Uric acid providesan antioxidant defense in humans against oxidant and radicalcaused aging and cancer. Proc Natl Acad Sci 1981; 78:6858 – 6862.

11 Ward JH. Uric acid as an independent risk factor in thetreatment of hypertension. Lancet 1998; 352:670-671.

12 Wang F. Drug insight: The role of albumin in the managementof chronic liver disease. Gastroenterolgy Today 2007; 11: 75-82.

13 Davies KJA. Protein damage and degradation of oxygenradicals. J Biol Chem 1987; 262: 9895 - 9902.

14 Koracevic D, Doracevic G, Djordjevic A et al. Method formeasurement of antioxidant activity in human fluids. J ClinPathol 2001; 54: 356 - 361.

15 Burtis CA, Ashwood ER. Photometric method for the

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determination of ascorbic acid. Text Book of Clinical Chemistry3

rd ed. Philadelphia, WB Saunders. 1998; 1025.

16 Hashim SA, Schuttringer GR. Rapid determination of tocopherolin macro and micro quantities of plasma. Am J Clin Nutr 1996;19 : 137 – 144.

17 Sinha SN. Estimation of Vitamin A. Practical ChemicalPathology. Sahitya Bhandar, Allahabad. 1

st ed. 1986; 21 – 22.

18 Caraway WT. Standard Methods of Clinical Chemistry,Academic Press, New York. 1963; 4: 239-240.

19 Doumasa BT, Watson WA , Biggs HG. Albumin standardsand the measurement of serum albumin with bromocresolgreen. Clin Chem Acta 1971; 31: 87-96.

20 Utley, HG, Bernheim, F, Hochstein, P: Effect of sulfhydrylreagents on peroxidation in microsomes. Arch BiochemBiophys 1967; 118: 29-32.

21 Sinha SN. Determination of serum sodium and potassium.Practical Chemistry Pathology. Sahitya Bhandar, Allahabad.1986; 118.

22 Neill DW, Neely RA. Estimation of serum magnesium. J ClinPath 1956; 9 : 162.

23 Trinder P. Estimation of serum calcium level. Analyst 1960;85 : 889.

24 Singh S, Saxena R, Lal AM. Influence of aging on plasmaascorbate level. Natl Acad Sci Lett 2005; 28 : 125-127.

25 Harman D. Aging and disease extending functional life span.Annals of the New York Academy of Sciences. 1996; 786:321-326.

26 Girolti AW. Regulation of enzymatic lipid peroxidation: theinterplay of peroxidizing and peroxide reducing enxymes.Free Rad Bio Med 2002; 33 :154-172.

27 Goldberg ED, Bowen LT, Farrington JW, et al. EnvironConserv 1978, 5:101.

28 Saxena R, Jaiswal G. Lipid peroxidation mediated electrolyteimbalance in patients with different stages of essentialhypertension. S As J Prev Cardiol 2006; 10: 143-147.

29 Kim M, Akera T. Oxygen free radicals : cause of ischemia– reperfusion injury to cardiac Na

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+ ATPase. Am J Physiol

1987; 252 : 252 – 257.

30 Yarnell JWG, Baker IA Sweetnam PM. Fibrinogen, viscosityand WBC count are major risk factors for Ischemic HeartDisease. Circulation 1991; 83 : 836 – 844.

31 Yang DB, Lin H, Mc Cabe RD. Potassium cardiovascularprotective mechanisms. Am J Physiol 1995; 268 : 825 – 837.

32 Zemel MB. Calcium modulation of hypertension and obesity: mechanisms and implications. J Am Coll Nutr 2001; 20 :428 – 435 .

33 Mc Cabe RD, Bakorich MA, Srivastava K et al. Potassiuminhibits free radical formation. Hypertension 1994;24 : 77 –82

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: 1305 – 1310.

35 Vasdev S, Longerich L, Ford CA. Role of aldehydes inhypertension. Adaptation Biology and Medicine. (Vol.1) NarosaPublishing House, New Delhi. 1997; 326 – 339.

36 Duthie GG, Bellizzi. Effects of antioxidants on vascular health.Br Med Bull 1999; 55 : 568-577.

37 Heitzer T, Just H, Munzel T. Antioxidant Vitamin C improvesendothelial dysfunction in chronic smokers. Circulation 1996;94 : 6 – 9.

38 Vasudevan DM, Sree Kumari S. Text Book of Biochemistry.3

rd ed. Jaypee Brothers Med. Pub. Ltd., New Delhi. 2001; 233-

239.

39 Yashioka M, Matsushita T, Chuman Y. Inverse associationof serum ascorbic acid and blood pressure in male adultsaged 30 – 39 years. Int J Vitamin Nutr Res 1984; 54 : 343– 347.

40 Prithviraj T, Misra KP. Reversal of Atherosclerosis – Fact orFiction? Cardiology Today 2000; 4 : 97 – 100.

41 Culter RG. Antioxidants and aging. Am J Clin Nutr 1991; 53:373 -379 .

42 Mohan A, Jain APa Mohan C. Vitamin E : pertinence andfunctional role in human diseases. JAMA India 2001; 4 102-105.

43 Olivieri O, Stanzial AM, Girelli D et al. Selenium status, fattyacids, vitamin A and E, and aging: the Nove study. Am J ClinNutr 1994; 60: 510-517.

44 Ugle SS, Patel MB, Yadav AS et al. Low Beta-carotene andelevated lipid peroxides in blood and LDL are major causesof cardiovascular disease in smokers. S As J Prev Cardiol2006; 10; 230-233.

45 Burton GW, Ingold KU. B-carotene is an unusal type of lipidantioxidant. Science 1984; 224:569-573.

46 Ogura T, Matsuura K, Matsumoto Y. Recent trends ofhyperuricemia and obesity in Japanese male adolescents.Metab Clin Exp 2004; 53 : 448 – 453.

47 Schlotte V, Sevanian A, Hochstein P et al. Effect of uric acidand chemical analogues on oxidation of human low densitylipoprotein in vitro. Free Rad Bio Med 1998; 25 : 839 – 847.

48 Maurya PK, Rizvi SI. Age associated changes in biomarkersof oxidative stress. Journal of Indian Academy of Geriartics2006; 2 :144.

49 Adiga U, D’souza J, Kousalya R, et al. Total antioxidant activityin Parkinson’s disease. Biomedical Research 2006;17: 145-147.

50 Baweja S, Mathur A, Agarwal H, et al. Nutritional assessmentin geriatric practice. Journal of Indian Academy of Geriartics2006; 2 :107-114.

51 Agarwal A , Prabhakaran S. Mechanism, measurement andprevention of oxidative stress in male reproductive physiology.Ind J Exp Bio 2005; 43: 963 - 974.

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Original Article

Life-Satisfaction Among Rural Elderly Females inChittoor District

Swarnalatha N

Abstract

The aim of this study was (1) To study the level of satisfaction among the aged women (n=400) (2)To ascertain association between life-satisfaction and socio-demographic factors like age, marital status,educational attainment, occupation etc. (3) To analyze the linkage between economic condition and life-satisfaction. The study was undertaken in the villages of Rural Health Centre, Chandragiri, Chittoor district,as part of field practice centre for Community Medicine, Sri Venkateswara Medical College, Tirupati. Resultsindicate that with increase in age life-satisfaction showed a decline and it was statistically significant. Highlevel of satisfaction was observed in nuclear families (31.9%) while it was 26.4% in joint families. Theproportion of widowed or separated respondents scored low on life-satisfaction (35.8%) and it was statisticallysignificant. As literacy level increased, the level of low satisfaction also increased however it is not statisticallysignificant. The elderly women who were engaged in income generation activity, those women whose spousewere head of the family or living with them, women having high economic status and women who wererespected and consulted scored high level of satisfaction.

(Journal of The Indian Academy of Geriatrics, 2007;3 145-149)

IntroductionOne of the significant aspects of the lives of older

people is their feeling of life-satisfaction. The feelingof satisfaction with their lives offers a sense ofcontentment and fulfillment of a large portion of theirfelt needs. The correlates of life-satisfaction amongelderly were carried out in many researchers on a studyon determinants of life-satisfaction. Results showedthat, the significant contributors to life-satisfaction werepositive health, functional ability, self acceptance ofageing changes, perception of social supports,intergenerational interaction, religiosity, self-rating ofability in activities of daily living, economic security,self rated behavioural flexibility, externality, belief inkarma (fate) and rebirth philosophy.1 Chadha emphasizeson gender differences and reports that elderly femalesare less satisfied from life than their male counterparts.2

Many of these differences could be traced to thedifferential roles assigned to women both in urban andrural areas. This gives rise to several prickly issues:is life-satisfaction an intrinsic or extrinsic variable, oris it dependent on factors like age, gender, type offamily, literacy status, economic status etc.?

Old age is considered to be the last chapter oflife. Though, a universal phenomenon, it is not a uniformexperience among senior citizens. Some personsachieve a sense of fulfillment and satisfaction in theirold-age, while others turn bitter and lament the declineof their physical abilities and social significance.Erickson asserts that elderly people review their pastlife and if they feel that most goals of their life havebeen fulfilled, they feel satisfied (ego-integration).Conversely, a feeling that not much has been achieved,brings a sense of despair among the aged becauseit may be too late to make amends.

There is a strong positive correlation between life-satisfaction and level of activity among the elderly.Jamuna & Ramamurti and also Abrams record thatageing brings negative changes in self-concept and life-satisfaction with increase in emotionality and rise in

Assistant Professor, Department of Community Medicine,S. V. Medical College, Tirupati, AP.

Address for Correspondence:Dr N Swarnalatha, MD, Assistant Professor,Department of Community Medicine,S. V. Medical College, Tirupati-517507 A.P.email: [email protected]

146


frustration tolerance.3,4 Females more often have lowlevels of satisfaction and the variable is stronglyassociated with relational variables like maritalhappiness, rather than socio-economic factors likeincome level. Adelmann observes that there is a strongpositive association between multiple roles andpsychological well-being among aged people.5 Multipleroles (like spouse, parent, homemaker, grand-parent,caregiver, employee, volunteer etc) are associated withhigher life-satisfaction and lower depressive symptoms.Chadha et al. maintain that married older people havea high level of satisfaction as compared to their widow/widower counterparts.6 Ardelt asserts that wisdom(defined as a composite of cognitive, reflective andaffective qualities) has a profoundly positive influenceon life-satisfaction, particularly among aged women.7

Study of Elango on life-satisfaction and dependencyamong rural and urban elderly revealed that there weresignificant differences between rural and urban elderlywith regard to life-satisfaction and dependency.8 Howeverwhen life-satisfaction scores were compared betweenrural and urban males separately and rural and urbanfemales separately, the differences were not statisticallysignificant.

Due to breakdown of joint family and tremendousinfluence of modern lifestyles on the younger generation,the attitudes of the young people towards old age areconstantly changing and thus for many, old people inthe house become a sort of burden and liability. Itbecomes rather difficult for those elderly to change theirideas, views and opinions suddenly to adjust with theyounger generation. Supportive close relationships areparticularly crucial for the elderly who left their spouseor other close person. Many old people belonging tolower and middle class groups do not have enoughsavings to take care of their needs and are economicallydependent on their children for their security. Manyold people feel that they would prefer to stayindependently in the near vicinity of their children andwould like to retain their independence.

Though these studies provide invaluable information,these do not pay a focused attention on life-satisfactionamong elderly women. The present paper attempts tobridge this gap.

Objectives1) To study the level of satisfaction among the

aged women.

2) To ascertain association between life-

satisfaction and socio-demographic factors like age,marital status, educational attainment, occupation etc.

3) To analyze the linkage between economiccondition and life-satisfaction.

Definition: For the purpose of the present study,life-satisfaction may be defined as the feeling ofcontentment and happiness the aged women has,especially, from her past-life.

Material and MethodsThis study was carried out in 9 villages which were

selected randomly and these areas were covered bythe field practicing areas of Chandragiri Rural HealthCentre of S.V. Medical College in Chittoor district ofAndhra Pradesh from February 2001 to January 2002.

Data collection was carried out on 400 olderwomen (60+) by house-to-house visit in the studyvillages. The identified 400 older women were interviewedin their local language and examined. All the womenhad voluntarily participated in the interview. As per theinterview schedule, the socio-demographic informationof the sample was collected. Socio-economic statusof the women was assessed using the modified versionof Udai Pareek classification.9

In order to measure life-satisfaction among therespondents, the scale developed by Neugarten,Havighurst and Tobin, namely “Life-Satisfaction Index”was used. The summarized rating scale has 20 itemsand has the reliability (split-half) of 0.82(p<0.001). Forpositive statements, weight ‘3’ was given for theresponse ‘agree’, ‘2’ for ‘uncertain’ and ‘1’ for disagree.Reverse weight was given to negative statements. Thelife-satisfaction measure is a sum of ratings as fivedifferent components. An individual is regarded asenjoying psychological well-being to the extent that i)she takes pleasure from the round of activities thatconstitute her every day life ii) regards her life asmeaningful and accepts resolutely that which life hasbeen iii) feels she has succeeded in achieving her majorgoals iv) holds a private image of self and v) maintainshappy and optimistic attitudes and moods.

Results and DiscussionIn the present study, 66.3% of women belonged

to 60-69 years of age. With increase in age life-satisfaction level showed a decline (50.9% among 60-69 years age group and only 12.0% among elderlywomen 80 years and above) and it is statistically

147


significant. Study of Elango showed that 46.0% ofelderly were having life-satisfaction while 21.0% werehaving somewhat satisfactory life and 33.0% did nothave a satisfactory life.8 In the study by Padda et al53.6% of elderly were feeling satisfaction while 46.4%were not feeling so.10 Singh C et al reported that 46.8%of the aged persons had happy attitude and 53.2% had

either unhappy or indifferent attitude towards life.11

In the current study 37.3% of elderly womenbelonged to other caste while 32.5% were scheduledcaste and 28.2% were back-ward caste. In presentstudy 50.0% of scheduled tribes had high satisfactionfollowed by other caste (37.6%) who had high satisfaction.37.2% of back-ward caste had high satisfaction.

Table 1: Distribution of Elderly Women by Socio-demographic determinants.

Variable

Low Satisfaction

(n=118) No %

Satisfaction (n=132) No %

High Satisfaction

(n=150) No %

Total No %

?2 value

P-value

Signifi-cance

1) Age(yrs) 60-69 70-79

> 80

27 10.2 74 67.2 21 84.0

103 38.9 28 25.5 1 4.0

135 50.9 8 7.3 3 12.0

265 66.3 110 27.5 25 6.2

164.11

0.000

S

2) Caste ST SC BC OC

1 12.5 35 26.9 34 30.1 52 34.9

3 37.5 51 39.2 37 32.7 41 27.5

4 50.0 44 33.9 42 37.2 56 37.6

8 2.0 130 32.5 113 28.2 149 37.3

5.99

0.423

ns

3) Type of the family Nuclear Joint

64 34.1

58 27.4

64 34.0 68 32.1

60 31.9 86 26.4

188 47.0 212 53.0

6.24

0.182

ns

4) Marital Status Separated/ widowed Married

105 35.8 17 15.9

97 33.1 35 32.7

91 31.1 55 51.4

293 73.3 107 26.7

20.06

0.000

s

4) Education Illiterate Primary Middle Secondary Higher Secondary

114 30.2 6 33.3 1 33.3 1 100.0 0 0

125 33.2 6 33.3 0 0 0 0 1 100.0

138 36.6 6 33.3 2 66.7 0 0 0 0

377 94.3 18 4.5 3 0.8 1 0.2 1 0.2

6.17

0.629

ns

5) Occupation Not doing any work House-wife Gainful occupation

41 69.5 50 36.2 31 15.3

14 23.7 41 29.7 77 37.9

4 6.8 47 34.1 95 46.8

59 14.7 138 34.5 203 50.8

70.22

0.000

s

6) Relationship to HOF Others Mother Wife HOF

23 40.4 64 36.6 3 7.3 32 25.2

22 38.5 57 32.6 12 29.3 41 32.3

12 21.1 54 30.8 26 63.4 54 42.5

57 14.3 175 43.8 41 10.2 127 31.7

27.72

0.000

s

7) SE Status < 20 20-30 > 30

77 31.4 23 27.4 22 31.0

83 33.9 31 36.9 18 25.3

85 34.7 30 35.7 31 43.7

245 64.0 84 20.3 71 15.7

12.54

0.014

ns

8) Staying with Others Son Husband Alone

27 40.3 60 34.1 9 12.7 26 30.2

24 35.8 62 35.2 21 29.6 25 29.1

16 23.9 54 30.7 41 57.7 35 40.7

67 16.7 176 44.0 71 17.8 86 21.5

25.08

0.000

s

9) Status in the family Neglected Just neglected Looked after well Respected & consulted

13 33.3 52 35.3 48 28.7 9 19.1

12 30.8 44 29.9 62 37.1 14 29.8

14 35.9 51 34.7 57 34.1 24 51.1

39 9.8 147 36.7 167 41.7 47 11.8

8.01

0.237

ns

s

HOF (Head of family) S = Significant NS = Non significant

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In the present study 53.0% of elderly women wereliving in joint families while 47.0% in nuclear families.High level of satisfaction was observed in nuclearfamilies (31.9%) while it was 26.4% in joint families.Joint families might give more chances of clashes onaccount of role conflicts, attitudinal differences, etc.Women at the age of 60+ years, living with theirunmarried children also suffered from tension andanxiety related to vocational settlement and marriageof their children, which might be the reason for theirlow levels of life-satisfaction.

Data of the present study showed that among therespondents 73.3% were widowed or separated while26.7% were married. The proportion of widowed orseparated respondents scoring low on life-satisfaction(35.8%) was almost twice higher than their marriedcounterparts (15.9%). Among those respondents whoscored high on life-satisfaction, 51.4% were marriedand 31.1% widowed. So, presence of a life-partner inold age proved crucial for the life-satisfaction. Studyof Panda AK revealed that the proportion of widowedor separated respondents scoring low satisfaction(41.9%) was almost twice higher than their marriedcounter parts (22.6%).12 Asha and Subrahmanianstudy stated that married aged scored higher onpositive self concept and life-satisfaction than theircounterparts.13

94.3% of the elderly aged were illiterates. Only0.2% respondents had acquired education upto highersecondary education. As literacy level increased thelevel of low satisfaction was also increased. Thisindicates that as the educational level is increasing theadjustment with the family member is also decreasing.

The elderly women who were not doing any workwere scoring low on life-satisfaction (69.5%) comparedto their counterparts who were housewives (36.2%) orhaving gainful occupation (15.3%). The study revealsthat subjects who were engaged in income generationactivity were having high satisfaction level (46.8%).Similarly aged women who continued to maintain theirpreferred active life-style by involving themselves inhousehold chores generally had higher life-satisfaction(34.1%). The differences were statistically significant.

The women who were wives of head of the familyscored high level of life-satisfaction (63.4%) comparedto their counter parts [as mother to head of the family– 30.8%; others – (as sister, mother-in-law, sister-in-law, grand-mother etc.) 21.1%] and the differences were

statistically significant. Chadha points out that the agedliving with their family score much higher on life-satisfaction than their counterparts.2 The study reflectsthat ‘family’ is important for the elderly.

The elderly women who were having high socio-economic status scored high levels of life-satisfaction(43.7%) compared to counter parts with low socio-economic status (34.7%). 31.0% of high socio-economicelderly had low levels of life-satisfaction while 27.4%of middle socio-economic group had low life-satisfactionlevels and at the same time 31.4% of low socio-economic group had low levels of satisfaction.Thedifferences were not statistically significant.

In the present study, those women who werestaying with their husband (57.7%) had high levels ofsatisfaction than those who were living with their sons(30.7%) or living with their brother, sister, son-in-lawetc (23.9%). The women who were staying with theirhusbands had lesser low levels of life-satisfaction(12.7%) compared to the women who were staying withothers (40.3%) or with their sons (34.1%). 30.2% ofwomen living alone had low levels of life-satisfactionand the differences were statistically significant.

Respect given to the elderly women by their familydenotes their acceptance. It gives them a feeling ofself-worth and being needed. Apparently, this in turncontributes positively to their sense of satisfaction withlife. Data of the present study showed that there wasa strong and direct relation between the respect givenby family members to the elderly ladies and their life-satisfaction. The women who were respected andconsulted had high levels of satisfaction (51.1%)compared to neglected (35.9%), just looked after wellgroup (34.7%) and looked after group (34.1%). Howeverthe differences were not statistically significant.

ConclusionEnhancing the quality of life of the elderly is one

of the objectives mentioned in the National Policy ofOlder Persons in 1999. Life-satisfaction is a significantindicator to ascertain the quality of life of elderlypersons. It is more or less an intrinsic variable andnot dependent on religion, caste, and occupationalstatus. Added to this, married aged women are moresatisfied with the life than the widows. The reason maybe attributed to cultural conditioning of elderly womenthat they are dependent – socially, emotionally andfinancially – on their husband, Thus, it can be inferredthat ‘young-old’ ‘old-old’, irrespective of caste, creed,

149


literacy status – all share similar social andpsychological challenges and life-satisfaction is, moreor less, independent of socio-demographic variables.

Due to breakdown of the cultural and moral factorsthe elderly women were suffering frequently due to theoccurrences of conflicts with their daughter-in-law.Hence aged women are more often dissatisfied in jointfamilies. All interventions should be directed towardsempowering the family to care for their elderly relatives.Enhancing their adjustment in families would be a steptowards realizing the WHO goal of “Care for the elderlyis home bound”.

Elderly having gainful occupation had significantrelation with the study variable – life satisfaction. Agedwomen who had sense of security that their kith andkin would stand by them whenever the need arose wereoften satisfied with life. Therefore, economic indicatorhave stronger influence on life-satisfaction among theaged women.

Social acceptance and life-satisfaction go handin hand. Role in decision-making on family matter isa crucial indicator of the status elderly women enjoyin their families. It also signifies satisfaction with life.The elderly women who are involved in decision makingin the families often feel satisfied with life. Added tothis, taking initiative in household work is a functionof life-satisfaction. Willingly taking up household choresoften help aged women scoring higher on life-satisfaction.

For maximizing the life-satisfaction among theaged women, there is a need for holistic approach andconcerted efforts of family members, community, NGOsand government agencies. Though programmes like OldAge Pension and Day Care Centres have been a fewinterventions done by the government to amelioratesome of economic and social problems of the aged,there is a demand for sensitization of the families aswell as the elderly about the needs and problems ofthe elderly.

Formations of self-help groups, counseling,involvement of the elderly women in the family andcommunity affairs depending upon their physicalcapacity, yoga, meditation, spiritual workshops etc.,are a few intervention steps meant for adding life tothe grey years.

References1 Ramamurti PV. Life satisfaction in the older years. Indian

Journal of Gerontology 1970; 2: 68-70.

2 Chadha NK . Self-concept and life-satisfaction among Aged.Indian Journal of Gerontology 1991; 5: 47-54.

3 Ramamurthi PV, Jamuna D. Paper presented at XI WorldCongess of Sociology held at N Delhi, 1986.

4 Abrams R C. The Aging Personality. International Journalof Geriatric Psychiatry 1991; 1: 1-3.

5 Adelamann P K. Multiple roles and physical health among olderAdults: gender and ethnic comparisons. Research on Aging1994: 16: 142-166.

6 Chadha N K, Aggarwal, Mangle A P. Hopelessness, alienationand Life-satisfaction among aged. Indian Journal ofGerontology 1992; 6: 82-92.

7 Ardelt M. Wisdom and life-satisfaction in old Age. Journal ofGerontology Psychological Sciences 1997; 52: 15-27.

8 Elango S. A study of health and health related social problemsin the Geriatric population in rural areas of Tamilnadu. IndianJournal of Public Health 1998; 42 : 7-9.

9 T Bhaskara Rao. Sociology in Medicine, 2nd

edn., ParasMedical Publisher, Hyderabad, India, p 67-69.

10 Padda A S, Mohan V, Jagjit Singh, et al. Health profile of agedpersons in urban and rural field practice areas of MedicalCollege, Amritsar. Indian Journal Of Community Medicine1998; 23 : 72-76.

11 Singh C, Mathur JS, Mishra V N et al. Aged in a rural population.Indian Journal of Community Medicine 1995; 20 : 24-27.

12 Panda A K. Life-satisfaction among elderly females in Delhi.Help Age India, Research & Development Journal 2005; 11: 21-29.

13 Asha C B, Subrahmanian K A. Problems of elderly women.Indian Journal of Community Guidance Service 1990; 7 :61-67.

Review Article

Old Age and Frailty: Genesis and ManagementGoel A*, Dey A B**

Since 1980s, the use of the term “frailty” in thepractice of Geriatric Medicine has increased substantiallywith increase in older population in the society andbetter understanding of health problems in old age. Itis somehow analogous to the term “failure to thrive”in young children.

Frailty identifies older persons at increased riskof morbidity and mortality. However, it continues to beill defined in medical literature. Its concept underlinessome common concerns of older people:

1. Being dependent on others or at a substantialrisk of dependency.

2. Experiencing the loss of physiological reserves.

3. Experiencing detachment from the environment.

4. Having many chronic illnesses.

5. Having complex medical and psychosocialproblems.

6. Having atypical disease presentations.

7. Experiencing accelerated ageing.

Frailty is a state of global condition of impairedstrength, endurance and balance as well as vulnerabilityto trauma and other stressors. Some practitioners havelimited the use of the term frailty to those older peoplerequiring assistance to perform basic activities of dailyliving (ADLs). While others consider frailty as low foodintake, weight loss, low body mass index (BMI),decrease in ability to carry out important practical andsocial activities of daily living, or a state that may resultin an adverse health outcome. In biological terms frailtydenotes decline in multiple physiological functions andmost importantly skeletal muscle function in strength,

power and endurance.

Frailty was defined by Campbell and Buchner asa condition or syndrome which results from multisystemic reduction in the reserve capacity to the extentthat a number of physiological systems are close toor past the threshhold of symptomatic clinical failure.1

In clinical sense the definition of frailty should includethe following: multi-system involvement, instability,deterioration over time, consideration of heterogeneitywithin the population, an association with increased riskof death and most importantly an association withageing.

Frailty is often regarded as a biomarker of ageing.However, the chronological age is possibly a proxy formany adverse processes, while frailty, the risk foradverse outcomes due to losses in different domainsof functioning, relates directly to these adverseprocesses. A landmark paper on old age health byAmerican Medical Association in 1990 indicated thata quarter of older people can be regarded as frail andthe proportion would rise to close to 50% for thoseabove 85 years of age.2 In an ongoing study, the authorsclassified 35% of hospitalized older patients as frailas per defined criteria. Using frailty as the criterion toselect elderly persons who need geriatric interventionsand making accurate treatment decisions is better thanselecting persons based only on their chronologicalage.

Why some older persons become frail while othersdo not? There are several hypotheses to explain theconcept of frail health. Rockwood et al, proposed thatthe state of health in old age is like a beam balance,balancing the health assets and deficits.3 Patientswhose assets clearly outweighed deficits would be welland those in whom the balance was precarious or tiltedin favor of deficits, are frail. The essential feature offrailty as per this concept is the “notion of risk dueto instability.” Campbell and Buchner considered thatfrailty arises from a decline in the reserve of multiplesystems and is a state of “unstable disability”. 1 Lipsitzet al have constructed frailty in the model of mathematicalchaos theory suggesting that frailty occurs when the

* Senior Research Associate, ** Professor, Department ofMedicine, All India Institute of Medical Sciences, New Delhi.

Address for Correspondence:Dr A B Dey, Professor, Department of Medicine,All India Institute of Medical Sciences, New Delhi - 110029.email: [email protected]

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responses of an organism “lose complexity in restingdynamics and show maladaptive responses toperturbations".4 Bortz uses the concept of sym-morphosis which describes how different body structuresand functions co-adjust to different levels of organismicenergy flow and suggests that frailty is a result of earlydisease in multiple systems leading to impaired musclestrength, mobility, balance and endurance.5 Hougaardconsiders frailty as “a random effects model for timevariables, where the random effect (frailty) has amultiplicative effect on hazard".6

Pathogenesis of frailty in old age

The development of frailty depends on the interactionof age-related disease processes with the normativeage-related changes in organ functions, genes, lifestyleand environment. As mentioned earlier frail older peoplehave excessive loss of functional muscle tissue(sarcopenia). All disease process that limit an olderperson’s ability to exercise such as pain (due todegenerative joint diseases), cardio-pulmonary diseases(congestive heart failure, chronic obstructive pulmonarydisease etc), anemia, neuro-muscular diseases(diabetes, peripheral vascular disease, polymyalgiarheumatica, cerebrovascular diseases etc.), weightloss (due to any cause) and loss of executive mentalfunction (cognitive impairment, dementia, depressionetc.) can lead to frailty.

Sarcopenia and ageing

The term sarcopenia denotes loss of musclemass. A person is considered as sarcopenic whenthe lean body mass, which is generally considered asa sensitive indicator of muscle mass, is less than twostandard deviations of the gender specific mean of ayoung sample. Lean body mass can be derived frommeasurements using DEXA, though such determinationsare seldom required in clinical practice. There are manysimpler and cheaper technologies to achieve that aswell. The prevalence of sarcopenia using the abovedefinition is 12% between 60 and 70 years andincreases to about 30% above the age of 80 years.It must be noted here that fat accumulation occurs inskeletal muscles as we grow old and there can beuncoupling of muscle cross sectional area and musclefiber strength with ageing, and lean body mass maynot reflect the effective muscle strength in old age.7

Several predictors of sarcopenia in old age has beenidentified. These include: genetic predisposition, birthweight, energy intake, vitamin D status, physical

activity, insulin like growth factor (IGF)-1 level and mostimportantly testosterone status.

Clinical and biochemical features of frailty

The major clinical correlates of frailty are:

· muscle weakness

· fatigue and inactivity

· slow and / or unsteady gait

· weight loss

· impaired cognition.

It is likely that the manifestations of the primaryor underlying diseases would also be easily visible infrail older patients. Various biochemical abnormalitiesobserved in frail older subjects are:

· Increased blood levels of catabolic cytokines:C-reactive protein, IL-6

· Elevated markers of blood coagulation:D-dimer, Factor VIII

· Reduced hemoglobin levels: normocyticsubclinical anemia

· Reduced hormonal levels: growth hormone,insulin-like growth factor-1 (IGF-1), testosterone (inmen), dehydroepiandrosterone (DHEA) and estradiol (inwomen)

· Increased hormonal levels: cortisol (especiallypostmenopausal women); luteinizing hormone (in men)

· Decreased carrier protein levels: transthyretin,retinol binding protein, albumin

Diagnosis of frailty

Several diagnostic criteria have been advocatedto identify the frail older person. Each of them has itsown advantage and disadvantage. A simple test of frailtywould include a timed one-leg standing balance testand timed “Up and Go” (rising from chair, walking 3meters, turning and sitting down). More methodicaltests used for epidemiological research and clinicaldiagnosis include the one proposed by Brown et alwhich contains four objective tests: obstacle performancetest, a test of hip abduction strength, the semi-tandemportion of Romberg test and the peg board test.8

The author, however, follows the diagnostic criteriaproposed by Fried et al, which requires demonstration

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of three out of five features:9

1. Unintentional weight loss of greater than 4.5kgin the last year or BMI <18.5

2. Slow walking speed measured by a stop watch

3. Objective evidence of weakness assessed bygrip strength

4. General feeling of exhaustion

5. Low levels of physical activity.

Treatment and prevention of frailty

From the above discussion it may be obvious thatolder people at some point of time will enter into aphase of frailty as a result of inevitable and progressivebiological decline. As has been indicated the commondeficits detected in frail older people are muscleweakness, muscle wasting, exercise de-conditioning,functional deficit in multiple domains resulting infrequent falls, decline in mobility and incontinence.These deficits contribute to each other over a periodof time finally leading to hospitalization orinstitutionalization.

Thus the first strategy in the management of frailtyis prevention. There is a substantial long term dataavailable in world literature which suggests that withcontinuous physical exercise programme and adequatenutrition the risk of frailty can be reduced in advancingyears. The effective exercise programme which helpspreventing frailty in old age should include:

· Aerobic conditioning: At least 20 minutes ofphysical activity achieving 50-75 percent of target heartrate three times per week. The best example of suchan exercise programme is brisk walking which olderadults can easily perform.

· Weight resistance training: This includes 3sets of 8 to 15 repetitions of resistance training at leasttwice a week.

· Flexibility/stretching training: This includes atleast 15 seconds of static stretching per muscle groupdaily.

· Balance training: Though, there is no standardbalance training exercise available some of the promisingactivities include yoga-asanas, tai-chi and dancing.

Good nutrition can prevent many of the contributorsof frailty which include osteoporosis, malnutrition and

obesity (and attendant cardiovascular diseases).Evidence suggests that diet with following modificationshave substantial influence in reducing the risk of theabove morbidity and frailty.

· Low fat: less than 30 per cent of calories andless than 10 per cent derived from saturated fats.

· Low sodium: maximum of 5gm sodium.

· High calcium: 1200mg calcium either from foodor supplementation.

· Vitamins and minerals: derived from fruits andvegetables in adequate quantity can provide mostvitamins and minerals required by older people.Supplementation of vitamin D, folic acid, vitamin E andselenium is advisable for bone health, controllinghomocysteine levels and antioxidants supplementation.

· High fiber: from fruits, vegetables and grainsin adequate quantity.

While managing older patients with frailty theemphasis should be on:

· Comprehensive geriatric assessment to detectthe deficits in function, risk factors and disease states.

· Treatment of diseases as per establishedpractice.

· Prevention of adverse drug reactions by adoptingsafe prescription guidelines.

· Physiotherapy and reconditioning of musclegroups.

· Nutrition supplementation for deficits.

Among the common conditions which are amenableto treatment easily are: anemia of chronic disease orrenal disease with erythropoietin, relief from pain andthereby muscle wasting by analgesics andphysiotherapy, vitamin D deficiency by supplementationand treatment of depression with selective serotoninreuptake inhibitors. While control of diabetes in olderpatients is not very difficult, management of chroniccomplications of diabetes, cognitive impairment andintractable heart failure is often challenging.

No single agent can be recommended for treatmentof frailty. Molecules which appear promising includespecific androgen receptor modulators and growthhormone or its analogues. Anabolic steroids oftenproduce a sense of well being though not sustained

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for long periods. Thus the practitioner of old age caremust look at diligent assessment and non-pharmacological methods for management rather thanlooking for any miracle remedy for frailty in old age.

References1. Campbell AJ, Buchner DM. Unstable disability and the

fluctuations of frailty. Age Ageing 1997;26:315-318.

2. American Medical Association white paper on elderly health.Report of the Council on Scientific Affairs. Arch Intern Med1990;150:2459-2472.

3. Rockwood K, Fox RA, Stolee P, et al. Frailty in elderly people:an evolving concept.CMAJ 1994; 150:489-495.

4. Lipsitz LA. Dynamics of stability: the physiologic basis offunctional health and frailty. J Gerontol A Biol Sci Med Sci2002;57:115-125.

5. Bortz WM 2nd

. A conceptual framework of frailty: A review.J Gerontol A Biol Sci Med Sci 2002; 57: 283-288.

6. Hougaard P. Frailty models for survival data. Lifetime DataAnal 1995;1:255-273.

7. Morley JE, Baumgartner RN, Roubenoff R, et al. Sarcopenia.J Lab Clin Med 2001;137:231-243.

8. Brown M, Sinacore DR, Binder EF, et al. Physical performancemeasures for the identification of mild to moderate frailty. JGerontol A Biol Sci Med Sci 2000; 55: 350-355.

9. Fried LP, Tangen CM, Watson J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci2001; 56: 146-156.

Post Graduate Diploma in Geriatric MedicineSchool of Health Sciences

Indira Gandhi National Open UniversityMaidan Garhi, New Delhi-110068, India

www.ignou.ac.in

This programme is a Diploma Programme of one year duration. It is aimed at MBBS doctors. This

programme will equip the in-service doctors with knowledge and skills in the field of Geriatric Medicine

and further enable them to deal with the special problems faced by the elderly.

The broad Objectives of the Programme are to:

? Upgrade the knowledge and skills for providing comprehensive health care to elderly

? Inculcate the inter-disciplinary approach for diagnosing and management of geriatric health

problems

? Improve the clinical, social and communication skills by providing hands on training inmedical colleges and district hospitals

Delirium in ElderlySingh R*, Coutin I B**, Kejriwal K***

Review Article

Delirium, characterized as an acute decline ofattention and cognition, is a common and seriousproblem for hospitalized elderly. The incidence ofdelirium is 14-56%, while hospitalized mortality ratevaries from 25% to 33%. This has been associatedwith poor long term outcomes. Moreover, deliriumrepresents one of the most preventable adverse eventsfor hospitalized seniors. It is often iatrogenic and manyaspects of hospital care, including adverse drugreactions, complications of procedures andimmobilization contribute to its development.1-4

Rarely delirium is caused by a single factor; ratherit is a multifactorial syndrome resulting from theinteraction of vulnerability on the part of patient ( i.e.the presence of predisposing conditions, such ascognitive impairment, severe illness or visual impairment)and hospital related insults (i.e. medications andprocedures ). The risk of delirium increases with numberof risk factors.5-9

Therefore, a multicomponent approach targeted tothe patient’s risk factors is the most clinically relevantand potentially effective intervention for delirium.

Assessment and RecognitionIn all settings, delirium is often unrecognized or

mistaken for dementia, depression or acute psychosis.1

Healthcare professionals and family members oftendismiss the signs of delirium as part of normal agingor as an expected part of the terminal illness. Riskfactors for under recognition of delirium in older personsalso include baseline cognitive impairment, visual orhearing impairment, and lethargy.10-15

DSM -IV definition16

A. Disturbance of Consciousness (reduced clarity

of awareness of the environment) with reduced abilityto focus, sustain or shift attention.

B. Change in cognition (memory deficits,disorientation, language disturbances) or perceptualdisturbances not accounted for by preexisting dementia.

C. Caused by general medical condition orsubstance-induced ( drug of abuse, medication or toxinexposure)

D. Acute change( hours to days) and fluctuation(during the course of day)

sychomotor agitated/lethargic usually normal

allucinations may be present usually not

leep-wake cycle abnormal usually normal

peech slow, incoherent aphasic, anomia

sychomotor agitated/lethargic usually normal

allucinations may be present usually not

leep-wake cycle abnormal usually normal

peech slow, incoherent aphasic, anomia

(DSM-IV)(DSM-IV)

Delirium vs Dementia

onscious or alert

nset acute/subacute chronic

ourse fluctuating slow decline

rientation disorganized disoriented

ttention distracted usually nl

onscious or alert

nset acute/subacute chronic

ourse fluctuating slow decline

rientation disorganized disoriented

ttention distracted usually nl

(DSM-IV)(DSM-IV)

Delirium vs Dementia

* Geriatric Fellow, ** Head & Programme Director, ***AssociateProgramme Director, Department of Geriatric Medicine,Kaiser Permanente, Fontana, California

Address for Correspondence:Kamal Kejriwal, Assistant Clinical Professor,Department of family Medicine, Loma Linda University,Loma Linda, CAemail: [email protected]

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Confusion Assessment Method (CAM)

1. Acute onset and fluctuating course2. Inattention3. Disorganized thinking4. Altered level of consciousness.

– Consider Delirium if 1 and 2 andeither 3 and 4 present

– CAM easy to administer, sensitivity94-100% specificity 90-95%.17

ANTIPARKINSON CV DRUGS INSOMNIA MUSCLE Relax.

CORTICOSTER. H2 BLOCKERS NSAIDS SEIZURE

URIN INCONT ANTIBIOTICS

THEOPHLLYINE NARCOTICS

EMPTYING DRUGS GERO-PSYCH

ENTFlaherty JH. Clin Geriatr Med 1998

Drugs that can cause an ACUTE CHANGE IN MSDrugs that can cause an

ACUTE CHANGE IN MS

Risk Factors for DeliriumThe risk factors for delirium are subdivided into

predisposing causes and precipitating factors.Predisposing risk factors are present prior to the illnessand include cognitive or sensory impairments,polypharmacy, and malnutrition. Precipitating risk factorsinclude events that occur during the illness such asrestraints, surgery, and administration of psychoactivemedications. It is the interaction of these factors thatleads to delirium in elderly population.

For example, an older person with severalpredisposing risk factors (such as advanced dementia,advanced age, and malnutrition) may only require aminor insult such as a urinary tract infection to developdelirium. Compared to younger patients, older personstend to have high baseline vulnerability with risk factorsthat are less amenable to change such as high co-morbidity, compromised renal and liver function, andimpaired physical and cognitive function. The precipitantrisk factors which could be reversible by medicalintervention such as medications, immobility, restraints,dehydration, or electrolyte abnormalities. The clinician’stask is to identify predisposing and precipitating riskfactors which are easily correctable or reduced.18-19

Common causes

Some common causes for delirium are outlinedin a mnemonic for ‘delirium’ that includes the following:dementia, electrolytes, lung or other organ disease,

Confusion Assessment Method (CAM)

1.Acute onset and fluctuation courseAnd

2.Inattention

AND Disorganized thought and speech 4. Altered level of consciousness

infection, rx (medications), injury or pain, unfamiliarenvironment, and metabolic derangements.

Common predisposing factors• Age > 80 years

• Psychoactive drugs

• Poly-pharmacy

• Infection

• Metabolic disturbance

• Elevated blood urea, s creatinine

Common Preciptating factors are 20-21

Multiple medical problems

• Dementia

• Sensory impairment

• History of Ethanol abuse

• Limited ambulation

• Limited social interaction

• Fever / hypothermia

Fractures

Medications associated with delirium

In general, older persons even with a normal serumcreatinine may have a reduced capacity to metabolizeeven routine doses of hypnotics and sedatives. Thus,careful attention to dosages and types of agents couldhelp reduce the risk of delirium. Creatinine clearanceshould always be calculated in the elderly even witha normal serum creatinine. Three classes of drugs are

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most often associated with delirium, namely, sedative/hypnotics, narcotics, and anticholinergic medications.Anticholinergic medications include antihistaminicmedications such as diphenhydramine, antispasmodics(often used in terminal care to reduce abdominalspasms and to reduce secretions), tricyclicantidepressants (often used as adjunct therapy forneuropathic pain), antiparkinsonian medications, andantiarrhythmics.22,23 Other agents often associatedwith delirium include cardiac medications (digoxin,lidocaine), beta-blockers, H2-blockers, steroids,antibiotics, lithium, anticonvulsants, and NSAID’s.Opioid agents are of particular concern in the olderpopulation with accumulation of the medication and itsmetabolites occurring with intake of higher doses andwith worsening kidney function.3,24 Meperidine shouldbe avoided for many reasons: (1) it is a poor analgesic,(2) it lowers the seizure threshold, and (3) it has thehighest risk of delirium among all the opioids due tothe slow clearance of its active metabolite,normeperidine. 23 Research has shown that the typeand number of medications are also important. Personstaking two or more psychoactive medications are 4.5times more likely to be delirious. Also, adding morethan 3 medications in a 24-hour period results in arelative risk of 4 for developing delirium. Similarly,persons taking 6 or more drugs are 14 times morelikely to develop delirium.23

Although the neuropathogenesis of delirium is notwell understood, it is commonly felt that suppressionor impairment of the cholinergic system is directlyrelated to delirium. Thus, medications that have stronganticholinergic properties are often linked with thedevelopment of delirium. Recent research has improvedour understanding of the interaction of differentanticholinergic medications and delirium. The conceptof total serum cholinergic burden implies that thecumulative or additive effect of anticholinergic medicationsis not only associated with the development of deliriumbut also the severity and duration. 25,26 Thus, multiplesmall doses of many anticholinergic medications maybe as deliriogenic as a large dose of one anticholinergicmedication. The clinician should review medicationsand attempt to reduce or eliminate medications withanticholinergic properties. A trial of safer alternativesshould be attempted.

Common herbal therapies are potentially associatedwith delirium. Several case reports and case serieshave documented possible links of some psychoactiveherbal therapies with delirium. As herbal therapies areconsidered nutritional supplements in some countries,

they are not monitored stringently. Thus, the true riskof the herbal therapies is unknown. Kava Kava andvalerian root are sedating anxiolytics, which may belinked with delirium when taken excessively. St. John’sroot used for depression can cause delirium whencombined with other antidepressants that enhance theserotonin system. Belladona is a pure anticholinergicagent, that is atropine, and thus is clearly associatedwith delirium.

Many chinese herbal medicines have beenadulterated with medications in toxic doses such asantidepressants, or NSAID’s, which may cause deliriumamong other adverse effects.

Differential diagnosis of DeliriumThe common differential diagnoses are dementia,

mild cognitive impairment, depression, psychosissecondary to psychiatric disorder and serotoninsyndrome.

The clinician should be able to differentiatedelirium from depression and dementia and be able toidentify the delirium superimposed on dementia or mildcognitive impairment.27-28

Delirium Dementia

Abrupt change Slow

Brief Does not remit

Impaired attention Normal attention except severecases

Fluctuating, reduced Clear level of consciousnessconsciousness (alert)

Incoherent or Speech is ordered exceptdisorganized speech. anomic or aphasic

Management of Deliriuma. Confirmation of delirium

As described above, the first part of themanagement of delirium is to identify a change, performa cognitive assessment and using a delirium tool,determine the presence of delirium. The next part istwo-pronged and both steps occur concurrently, (1) theidentification and management of potential causes andrisk factors and (2) the management of deliriumsymptoms, particularly agitation. In addition, it isimportant to maintain close contact with the family andkeep them apprised of the plan of care throughout theprocess.

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b. Identification and management of potentiallyreversible underlying causes

This strategy was developed for hospitalized olderpersons, but may apply to this population although withsome restrictions.29-31 Work-up may be limited by thesetting, home or hospice, where tests may not beeasily obtainable and transfer of the patient may notbe acceptable. Diagnostic procedures that areunpleasant or painful may be avoided if the focus ofcare has shifted to comfort. Supportive therapiesthemselves may also be burdensome. Understandingthe patient’s and family’s goals of care and doing acareful history and physical examination will help guidethe evaluation. Key features of the physical examinclude fever, focal neurological signs, frontal releasesigns, and asterixis. Typical signs of dehydration,hypoglycemia, hyper- or hypocalcemia can be sought.Laboratory evaluation can be sought if this is consistentwith previously established goals of care. The level ofaggressiveness of diagnostic procedures will dependon the patient and family goals of care, the burdenof the tests, and the likelihood of a remediable cause.When death is imminent, tests beyond the history andphysical examination are likely inappropriate. If alaboratory evaluation is sought, a targeted strategy mayinclude the following:

• Complete blood count

• Electrolytes (including calcium, magnesium, andphosphorous), blood urea, creatinine, and glucose

• Urinalysis

• Pulse oximetry

Clinicians should emphasize low burdeninterventions such as:

• Rehydration with hypodermoclysis

• Treatment of hypercalcemia with subcutaneousbisphosphonates.

• Identification and treatment of opioid toxicity.Signs include agitation, myoclonus, tactile hallucinations,and hyperalgesia and are due to accumulation of toxicmetabolites. Consider changing to a different opioid ata lower equianalgesic dose.

• Careful review of medications and identificationof potentially noxious medications. One can eitherdiscontinue, decrease the dosage, or change to analternate, less toxic agent.

c. Management of delirium symptoms

i. Non-pharmacological strategies

Clinicians can greatly impact the severity andcourse of delirium by educating patients, families, andstaff. Several non-pharmacological strategies may helpto prevent delirium and also assist in the treatmentof delirium, especially hypoactive delirium. These mayinclude:

• Limit or preferably, avoid the use of restraints.Use family members or sitters to keep agitated patientscalm and safe.

• Improvement of sleep with a sleep protocol tominimize interruptions, provide a calming environmentat bedtime.

• Encourage cognitive activities, such asreminiscence, event discussions.

• An early mobilization protocol with ambulationor range-of-motion exercises and avoidance of restrictingdevices like urinary catheters.

• Optimization of visual and hearing impairmentwith aids. Assessing the patient's dentures, visual andhearing aids at the time of admission. Advising familyto bring it in as soon as possible into the hospital.

The family can often be educated and empoweredto actively participate in this process by:

• Helping to maintain adequate fluid and nutritionalintake.

• Improving the structure and familiarity of thepatient’s immediate environment with recognizableobjects, pictures, blankets, etc.

• Constantly reorienting to decrease anxiety anddisorientation.32

ii. Pharmacological options

An important principle of the care of deliriousterminal patients is that the treatment of symptomsof delirium, specifically distressing agitation orperceptual changes, should never be withheld duringthe evaluation process. Although some have suggestedtreating hypoactive delirium with stimulants such asmethylphenidate,which can also cause or worsenperceptual disturbances and is not generally used.33

In general, agitated delirium is most responsive topharmacological treatment.3 Most of the

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recommendations concerning which class or agent touse and under what circumstances come from expertopinions.34 Rigorous randomized clinical trials in olderpersons have yet to be performed to guidepharmacological management of delirium.

Agitation, hyperactivity, and aggressiveness aretreated with sedatives or neuroleptics, the latter withthe potential added benefit of improving cognition.Among the neuroleptics, haloperidol has remained themost widely used agent to control agitation inhospitalized and terminal patients. It has manyadvantages; it is versatile (available orally, parenterally),it has a wide therapeutic window, and carries minimalrisk of respiratory depression. In older persons, especiallythose with cognitive impairment, the lowest dosenecessary is recommended. Starting doses forhaloperidol are 0.5 to 1.0 mg every 30 minutes untileffect. Recent evidence shows that dopaminergicreceptors may be saturated at 5 mg in a 24-hour period,thus usual maximal doses should not exceed 5 mgper 24 hours.35 In addition, clinicians should keep inmind that parenteral doses are generally twice aspotent as oral doses and switching to oral therapyshould be accomplished as soon as possible. If furthersedation is required, alternating doses with abenzodiazepines (at low doses) is the safest nextstep.35

Atypical neuroleptics, such as olanzapine andrisperidone, are also used empirically in agitateddelirium. They are more beneficial for long-term usagedue to reduced extrapyramidal effects compared tohaloperidol. When sedation is the primary goal,benzodiazepines may be the class of choice due totheir rapid onset and ease of titration. They can alsobe used in conjunction with a neuroleptic. Among themost commonly used are lorazepam and midazolam.The former drug is available orally and parenterally withmost clinicians being quite familiar with its use. Again,the lowest possible dose should be used with a planto decrease or discontinue the medication oncesymptoms have resolved.35

ConclusionDelirium is very common to be missed in elderly.

This could lead to increase in length of hospitalizationand poor quality of life in elderly.

Through prompt identification of precipitating factorsand timely management, one can improve the outcomein elderly.

References1. Gustafson Y, Brannstrom B, Norberg G, et al. Underdiagnosis

and poor documentation of acute confusional states in elderlyhip fracture patients. J Am Geriatr Soc 1991;39:760-765.

2. Inouye SK, Foreman MD, Mion LC, et al: Nurses’ recognitionof delirium and its symptoms: Comparison of nurse andresearcher ratings. Arch Intern Med 2001;161:2467-2473.

3. Casarett DJ, Inouye SK. Diagnosis and managementof delirium near the end of life. Ann Intern Med 2001;135:32-40.

4. Breitbart W, Jacobsen PB. Psychiatric symptommanagement in terminal care. Clinics in Geriatric Medicine1996;12:329-347.

5. Levkoff SE, Evans DE, Liptzin B, et al. Delirium: The occurrenceand persistence of symptoms among elderly hospitalizedpatients. Arch Intern Med 1992;152:334-340.

6. McNicoll L, Pisani MA, Zhang Y, Siegel M, Ely EW, Inouye SK.Delirium in the Intensive Care Unit: Occurrence and ClinicalCourse in Older Persons. J Am Ger Soc 2003; 51 ; 591-598.

7. Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes,and outcome of delirium in patients with advanced cancer.Arch Int Med 2000;160:786-794.

8. Pereira J, Hanson J, Bruera E. The frequency and clinicalcourse of cognitive impairment in patients with terminalcancer. Cancer 1997;79 :835-842.

9. Blessed G, Tomlinson BE, Roth M. The association betweenquantitative measures of dementia and of senile change inthe cerebral grey matter of elderly subjects. Brit J Psychiatry1968;114:797-811.

10. Jorm AF. A short form of the Informant Questionnaire onCognitive Decline in the Elderly (IQ CODE): development andcross-validation. Psychol Med 1994;24:145-153.

11. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”: Apractical method for grading the cognitive status of patientsfor the clinician. J Psychiatr Res 1975;12:189-198.

12. Weschler D. Manual for Weschler Adult Intelligence Scale.New York ( NY): Psychological Corp 1955.

13. Trzepacz PT, Mittal D, Torres R, et al. Validation of the DeliriumRating Scale-Revised-98: comparison with the Delirium RatingScale and Cognitive Test for Delirium. J Neuropsychiatry ClinNeurosci 2001;13: 229-242.

14. Albert M, Levkoff S, Reilly C, et al. The delirium symptominterview. J Geriatr Psychiatry Neurol 1992;5:14-21.

15. Breibart W, Rosenfeld B, Roth A. The Memorial DeliriumAssessment Scale. J Pain Symptom Manage 1997;13:128-137.

16. American Psychiatric Association . Diagnostic and statisticalmanual of mental disorders (4th ed.). Washington, DC.American Psychiatric Association, 1994, 123.

17. Inouye SK, Van Dyck CH, Alessi CA, et al. Clarifyingconfusion: The Confusion Assessment Method. A new

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method for detection of delirium. Ann Intern Med 1990; 113:941-948.

18. Elie M, Cole MG, Primeau FJ, et al. Delirium risk factors in elderlyhospitalized patients. J Gen Intern Med 1998;13:204-212.

19. Schor JD, Levkoff SE, Lipsitz LA, et al. Risk factors fordelirium in hospitalized elderly. JAMA 1992;267:827-831.

20. Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive modelfor delirium among hospitalized elderly persons based onadmission characteristics. Ann Intern Med 1993; 119:474-481.

21. Inouye SK, Charpentier PA. Precipitating factors for deliriumin hospitalized elderly persons: Predictive model and inter-relationship with baseline vulnerability. JAMA 1996;20;275(11):275:852.

22. Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and otheranticholinergic effects of diphenhydramine in hospitalizedolder patients. Arch Intern Med 2001; 161:2091-2097.

23. Marcantonio ER, Juarez G, Goldman L, et al. The relationshipof postoperative delirium with psychoactive medications.JAMA 1994;272:1518-1522.

24. de Stouts N, Bruera E, Suarez-Almazor M. Opioid rotation fortoxicity reduction in terminal cancer patients. J Pain SymptomManage 1995;10:378-384.

25. Flacker J, Wei JY. Endogenous anticholinergic substancesmay exist during acute illness in elderly medical patients.2001;56: 353-355.

26. Han L, McCusker J, Cole M,et al. Use of medications withanticholinergic effect predicts clinical severity of deliriumsymptoms in older medical inpatients. Arch Intern Med2001;161:1099-1105.

27. Fick D, Foreman M. Consequences of not recognizing deliriumsuperimposed on dementia in hospitalized elderly individuals.J Gerontol Nursing 2000; 26 : 30-40.

28. Fick D M, Agostino J V, Inouye S K. Delirium superimposedon Dementia: A Systematic Review. J Am Geriatr Soc 2002;50 : 1723-1732.

29. Inouye SK, Bogardus ST, Charpentier PA, et al. A clinical trialof a multicomponent intervention to prevent delirium inhospitalized older patients. N Engl J Med 1999;340:669-676.

30. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducingdelirium after hip fracture: a randomized trial. J Am GeriatrSoc 2001;49:516-522.

31. Meagher DJ. Delirium: optimizing management. BMJ2001;322:144-149.

32. McDowell JA, Mion LC, Inouye SK. A non-pharmacologicalsleep protocol for hospitalized older patients. J Am GeriatrSoc 1998;46:700.

33. Morita T, Otani H, Tsunoda J, et al. Successful palliation ofhypoactive delirium due to multi-organ failure by oralmethylphenidate. Support Care Cancer. 2000;8:134-137.

34. American Psychiatric Association: Practice guideline for thetreatment of patients with delirium. Am J Psychiatry 1999;156:1.

35. Breitbart W, Marotta R, Platt MM, et al. A double-blind trial ofhaloperidol, chlorpromazine, and lorazepam in the treatmentof delirium in hospitalized AIDS patients. Am J Psychiatry1996;153:231-237.

Current Perspective

Health Economics For GeriatricsKishore J*, Ingle GK**

IntroductionThere are 77 million (7.4%) elderly people in India

and this number is expected to rise to 178 million by2030.1 Analysis of the census data shows substantialvariation in the rate of demographic aging across India:10.5% of Kerala’s population is older than 60 yearswhile in Dadra and Nagarhaveli, this proportion is only4%. The majority of the elderly are very poor and livein rural areas. The government pension scheme currentlyreaches only 2.76 million out of 28 million elderly peopleand this is mainly in urban areas. The elderly havelittle hope of escaping poverty and subsequently theirsituation becomes worse as they are increasinglyplagued by chronic health problems. Particularly theimpoverished elderly women face a difficult situation,especially those who are widows. Considering their lowrank in society, the inability to work can mean aninability to survive on their own.

Modernization, urbanization and westernization ofIndian society have direct bearing on family particularlyelders. Modern society has failed to give due recognitionto the elderly which lead to isolation, sense ofworthlessness, depression and suicides. India ischaracterized by the existence of longstanding variationssuch as rural-urban dichotomy, rich and poor difference;the unequal distribution of resources, and unequalreach of modern technology. In this variation, elderlywho is physically weak faces the worst discrimination.There is poor allocation of resources for health whichdirectly affects quantity and quality of services. Withan increase in numbers of the elderly, the cost of publichealth care is expected to increase.2 For these reasonsan expert of geriatric care must understand the basicsof health economy.

Health Economics

Economics revolves around the study of marketsor exchange between producers and consumers.Production and consumption are among the mostfundamental activities of human being. Economists aretrained to examine problems of allocation of scarceresources. Economist focuses on how to do the bestmaximum with the available resources. They alsoassess who gets benefit and who looses from theactivities.

Economics applied to the health field is HealthEconomics. Health economics seeks inter alia toquantify over time, the resources used in health servicedelivery, its organization and financing; the efficiencywith which the resources are allocated and used forhealth purposes and the effects of preventive, curativeand rehabilitative services on individual and nationalproductivity.

The field of health economics emerged due to veryhigh growth in national health expenditure. Healthsector poses formidable challenge to economists dueto extreme situation of scarcity and unique complexities.Central concern of medicine is to go into the causesand treatment of ill health. Health economics cancontribute to the understanding of and solution to themyriad of problems facing health sector.

Despite important gains in the health status duringlast few decades, much remains to be done to achievethe health targets. Tight budget, inadequate access toprimary health care facilities, inefficiency, poor qualityof health care, changing disease profile and persistenthigh fertility rate are among the causes andmanifestations of malfunctioning system. Healtheconomics helps in understanding the problems andimproving efficiency of health services. Efficiency is ameasure of outputs against inputs. It tells the relationshipbetween the results obtained from a health programmeor activity and the efforts expended in terms of human,financial and other resources, health processes andtechnologies, and time. The assessment of efficiencyis aimed at improving implementation, and adds to the

*Professor, **Director Professor & Head,Department of Community Medicine, Maulana Azad Medical Col-lege, New Delhi 2

Address for Correspondence:Dr. J Kishore, Professor,Department of Community Medicine, Maulana Azad Medical Col-lege, New Delhi 2email:[email protected]

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review of progress by taking account of the results.3

Economy of Rural Elderly: Majority of the ruralelderly have depended on agriculture for the source ofincome. Most of them being illiterate and unemployedor low wage employees, continue to work for muchlonger hours, with greater financial insecurity amongthem. They do not have legal and other provisions toprotect their rights. Due to these reasons they are oneof the most vulnerable groups. They do not ownproductive assets, have little or no savings or incomefrom investments made earlier, have no pension orretirement benefits, and are not taken care of by theirchildren or they live in families that have low anduncertain income and a large contingent on theeconomic capacity of the family unit. In rural areas,most families suffer from economic crisis, as theiroccupations do not produce income throughout theyear. The tendency is to spend more on their growingchildren, while minimizing expenditure on aged parents;thus financial security for the elderly is very limited.4,5

This could be one of the reasons of higher stress,physical ill health and poor quality of life in rural elderlyand poor help seeking inspite of awareness.6 Economiccondition is worst in rural women because they livelonger than their male partner and do not have anysocial or legal ownership over family resources. In factwidowhood in the lower socio-economic groupscondemns elderly female to beg for their food and areleft without a meaningful life pattern or social functions.Socioeconomic and emotional problems, negative selfconcept, feelings of powerlessness, high level ofphysical and psychological stress are significant aspectsof elderly widows.

Health Burden in Geriatrics

In a multi-centric study, it is found that 5.6% ofolder persons (> 60 years) are living alone, mainlyfemales.7 Tobacco use, both as smoking and otherwiseis observed in 23.4% of the subjects studied. Poorvision is very common (45%) and 20% predominantlymales are suffering from hearing difficulty. Older personshave hypertension (38%), joint related problems (36%),bowel complaints (32%), urinary problems (13%),diabetes mellitus (13%), falls (9%), asthma (6.6%),pulmonary disease (5%) and tuberculosis (3%), andcancers (0.8%). According to another study of thenortheast India, 33% males and 47% of the femaleshad at least one disability; 60% of the males and 71%of females are suffering from one chronic illness. Dueto this heavy burden of disease, urgent need of health

care to elderly is demanded.8 However, according toanother report, hypertension was 72%; diabetes mellituswas 53%; coronary artery disease was 31%; arthritiswas 20%; prostate enlargement was 8%; cancer was6%.

Negative stereotypes concerning ageing and oldpeople are prevalent worldwide, which affect policydecisions and subsequent programmes. The proportionof elder people in world’s population is on an increase,which is responsible for rising neuropsychiatric disordersparticularly dementia and major depression. These twoare accounting respectively for one quarter and onesixth of all disability-adjusted life years (DALYs) in thisgroup. With the unprecedented pace of demographicaging, societies will have comparatively little time todevelop social and healthcare policies to deal with thehealthcare needs of the elderly in their population. Mostof the people with dementia live in developing countries,the prevalence rate being 60% in 2001 and predictedto increase to 71% by 2040. Predicted rates of increaseof dementia between 2001 and 2040 are by 100% indeveloped countries, but by more than 300% in India,China and the South Asian and Western Pacificregions. There are hardly any specialized services forold people in the government-run public healthcareservices as compared to other specialties in India.General health services remain clinic-based and typicallyinvolve long waits in crowded clinics for briefconsultations. The usual focus in these settings is on‘treatable’ acute pathologies and not on long-term care.Old people find it difficult to get to these clinics asit involves travel and use of transport. Doctors continueto be a rare commodity in rural settings. Free servicesintegrated with primary care will help to reduce the costof care. Financial support to caregivers who are unableto go for their daily work due to more pressing needsof the elderly, needs serious consideration. Geriatricpsychiatry units need to be established in psychiatrydepartments in all the medical colleges.

Utilization of Health Services

Health care is provided to the people mainly bypublic and private health sectors. By and largegovernment sector is providing free health services, andprivate sector is charging fees for service. About 80%of the people are seeking medical care from privatepractitioners whereas 80% of the indoor patients areadmitted to the government hospitals. Elderly inabsence of health insurance and family support mayfind it difficult to get health services.

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Health Financing

The resources are scarce. The government hasactually committed six percent (of the budget) toeducation and three percent to health. India’s Ministryof Health and Family Welfare has been allocated $3.4billion for this year’s budget, an increase of $886 millionfrom last year, to expand health care services in thecountry, including HIV/AIDS programmes. In terms ofGDP it is around 1.3% and along with householdexpenditure it is around 6% of GDP in our country ascompared to 12% spent by USA and UK. Out of totalgovernment expenditure 25% is spent by the CentralGovernment and the state governments spend 75%.

The expenditure by the state government variesfrom state to state. More than 60% is incurred onproviding curative services and only 26% on preventiveservices and remaining on administrative expenses.About 67% of the resources spent have gone to urbanareas. There is 93% to 97% expenditure on revenueand only 3% to 7% on capital. Of the revenueexpenditure, about 60% goes to salaries and 15% to30% for supplies and rest on other aspects of healthcare system.

The pertinent question is why resources shouldbe invested in health care of elderly. Boom in medicine,science and technology celebrates increase in longevityof human beings, which directly affects the economyof the world. Longer productive life of people helps inretaining people in workforce for longer periods i.e.,cutting down expenses involved in education, recruitmentand vocational training. Another benefit is their cumulativewisdom and experience that could be used for betterdevelopment. There are social benefits of elderly alsobecause they bridge the two generations by taking careof children, provide adolescent guidance, mentoring,and providing family assistance.9

For the Integrated Programme for Older Personsthe budget allocation during 2005-2006 was Rs.19.80crores which was revised to Rs. 14.00 crores, againstwhich the expenditure was Rs.14.00 crores. The budgetallocation for the year 2006-07 is kept at Rs 28 crore.The registered societies, public trust, charitablecompanies or registered self-help groups of olderpersons in addition to Panchayati Raj Institutions areeligible to get the assistance under this scheme. Against the budget allocation during 2005-06 of Rs 67lakh, the expenditure was Rs 47 lakh. This allocationis not sufficient as far as proportion of elderly amongtotal population is concerned. The government is

providing facilities for cataract operation free of chargeand in some states intra-ocular lenses are also freelyinplanted. In collaboration with Non-GovernmentOrganizations, government is providing ophthalmiccare, mobile medicare units, income generating projectsand support to old age homes, day care centers forthe elderly, research and advocacy as well as emergencyrelief. There are approximately 728 old age homes inIndia. Of these 325 are free of charge, 95 are on apay-and stay basis, and 116 have both free as wellas pay-and stay facilities. There are 278 old age homesavailable for the sick and 101 homes are exclusive forwomen.2 This number is very less as compared to therequirement.

Additional money is required to meet rising costof health care due to escalation of prices, increase insalaries, increases in cost of material and supplies,advancement of technology, need and demand for betterquality care. Hence resources have to be generated.Government alone is not in the position to meet theneeds.

The resources can be generated by launching theschemes such as (a) health insurance (b) user chargesand (c) other innovative approaches. Regulatedprivatization would attract more patients releasingpressure and money from public sector. There areadvantages, disadvantages and controversies regardingeach of the scheme approach.

Efficient utilization of resources

Efficient utilization can be achieved through allocationefficiency and internal efficiency:

Allocation Efficiency is concerned with theallocation of resources to the production of output,which yield the highest value from their use. Thusexisting mal-distribution of resources between primaryand tertiary health care sectors or preventive andcurative health care services needs to be corrected toimprove efficiency and results. Allocating more fundsfor preventive and promotive services can save morelives. It is a wise approach to prevent diseases thanallowing diseases to occur and treat them.

It may be emphasized that health service costis not a valid objective. The objective must be realizingthe same benefits from the lower cost or increasebenefits without adding to the cost. Neighboringdeveloping countries have better health indicators withless percent of GDP expenditure on health care e.g.Sri Lanka, Maldives, etc.

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Internal efficiency is concerned with the avoidanceof waste. Such wastage may be caused by deficientadministration, a lack of managerial capabilities. Dueto under funding of specific complementary input suchas drug, fuel and lack of working vehicle there wouldbe non-functioning of the manpower or ineffectivetreatment leading to inefficiency / wastages. Anotherexample is bulk purchase of drugs of limited use orearly expiry. According to reports, equipments worthhundred of crores are lying idle in hospitals of ourcountry.

To improve the efficiency a health professionalneeds to orient himself and become cost conscious.However, it must be properly understood that becomingcost conscious does not mean saving of the moneyfor the sake of saving.

Cost accounting

Cost accounting is the application of costing andcost accounting principles, methods and techniques.It is essential for efficient operations of the hospitalor programme. If carried out periodically and methodicallyit can help the hospital/health administration in:

i) Determining actual cost of operating eachdepartment/service,

ii) Cost of hospitalization per day,

iii) Detecting wasteful expenditure

Following cost analysis can be undertaken:

Cost object: A unit of service for which we wishto know the cost. As this becomes more specific, thecost accounting methodology becomes more complex.

Direct and indirect cost: Direct cost applies to onlyone cost that is directly linked with the service e.g.cost of X-ray film is the direct cost and cost spenton machine, manpower, electricity, and other servicesrequired to produce X-rays is indirect cost.

Household cost: Cost incurred by the beneficiariesto seek health care, e.g. expenditure incurred upontransport by the patient.

Full cost analysis: Total amount of money spenton particular health service.

Unit cost analysis: Amount of expenditure incurredon each unit of service, e.g. cost of vaccination of onechild.

Fixed cost: The cost incurred upon irrespectiveof volume of service provided, e.g. cost incurred onbuilding, equipment, salary, etc.

Variable cost: Cost which is dependent on volumeof service. Cost incurred upon drugs, reagents, isdirectly proportional to the number of patient treated.

Marginal cost: Extra cost incurred upon productionof one more positive result.

Setting a price: By using fixed and variable costcalculation, the price of the service can be set. Profitcan be estimated or subsidies can be worked out.

Opportunity cost: The money which otherwisecould have been earned during the lost time oropportunity, or due to restriction of budget allocationfrom the programme is withdrawn leading to loss ofthe programme.

Application of Cost Analysis

Cost analysis is beneficial for following reasons:

1. Input can be calculated by taking intoconsideration all the costs. The input output ratios canbe obtained to find out the efficiency and take correctivemeasures to improve the efficiency. Efficiency isobtained when more results are produced with sameinputs (time, person, money) or same results areobtained with less input.

2. The outcome can be studied in term of costeffectiveness, i.e. number of cases prevented, treated,or lives saved by spending particular amount of money.

3. To take a decision regarding introduction of newprogramme, e.g. prevention and control of hearing lossin elderly programme.

4. Cost of input and amount of money savedwhich otherwise would have been spent on treatmentand other aspects of the patient care should be takeninto consideration.

5. Estimations and projections can be made tohelp health policy makers and managers in decision-making.

Cost containment

Cost of the health services can be reduced withoutaffecting results by taking containment measures suchas

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· Buy prudently, stock minimally, issue accuratelyand spent frugally,

· Prevent pilferage and wastage by internalauditing and effective supervision,

· Reduction of 20% of cost on medicine can beachieved without impairing the quality of care andmaintaining patient satisfaction.

Physician can play important role in costcontainment of health services for elderly by:

· Reducing number of investigations

· Reducing number of prescribed drugs promotesrational use of drugs and decrease resistance.

· Prescribing equally effective cheaperalternatives.

· Reducing average length of stay in the hospitaldecreases the cost of treatment and increase complianceof treatment.

· Proper scheduling of patients and staff help inreducing waiting and better attention to patients.

· Developing cheaper and innovative technology.

· Evidence based research: There is need toestablish priorities for areas of research on ageing andstrategies to ensure that the ageing research sectorhad the capacity, capability and visibility to meetcurrent and future research needs.10 However, allresearch work should have component of healtheconomy to justify the need of intervention.

· Develop and support public private partnershipto strengthen financial resource for health care.

Thus by generating additional resources,reallocating the resources, taking cost containmentmeasures and avoiding wastages by applying costevaluating techniques, resources can be efficiently

utilized to provide cost effective health services andhealth services benefits can be obtained at lower cost.

ConclusionThe objective of health care is to save lives, prevent

and cure diseases, promote and maintain health, byproviding quality care to older persons. No cost is toogreat, when it comes to saving the elderly lives butsaving money out of extra expenditure may saveanother life. Health care is oriented to the health needs,service expectation and people’s aspiration and is notprofit oriented.

References1. Govt. of India. Census of India 2001. New Delhi: Registrar

General of India, Govt. of India.

2. WHO. Health of the elderly in South East Asia: A Profile. NewDelhi: WHO SEARO 2004.

3. Kishore J. A Dictionary of Public Health. New Delhi, CenturyPublications, 2007.

4. Bali AP. The role of family in elderly care. Helpage IndiaResearch & Development Journal 1995; 2:1.

5. Vijaya Kumar S. Old Age: A Challenge of life. Journal of IndianAnthropological Society 1990; 16: 3-4.

6. Vijaya Kumar S. Rural elderly: Health status and availablehealth services. Help Age India Research & DevelopmentJournal 1996; 2:3.

7. Srivastava RK. Multicentric Study to establish epidemiologicaldata on health problems in elderly: a Govt. of India and WHOcollaboration programme. Ministry of Health & Family Welfare,Government of India 2007.

8. Swain P. Health status among elderly in Northeast India.Journal of the Indian Academy of Geriatrics 2007; 3 :8-14.

9. Prakash IJ. Does longevity contribute to improving socio-economic health of the country? Journal of the IndianAcademy of Geriatrics 2007; 3: 121.

10. Mathur A. Population Ageing and Research. Journal of theIndian Academy of Geriatrics 2007; 3 : 95-96.

National Health Programmes of India: NationalPolicies and Legislations Related to Healthby J Kishore

Book Review

This is India’s first book on introduction to basic concepts of national health planning,programming, legislation and on the approach to public health problem. In recent yearsnational programmes and policies have become increasingly important in both public healthand clinical practice in India. This book consists of three sections. Section-I focuses onthe assessment of disease burden in the country, various preventive and control programmeson communicable and non-communicable diseases and reproductive health. Section II haselaborated important policies including National Policy on Older Person and Section III dealswith legislations. This new edition is thoroughly updated and new chapters on National FamilyHealth Survey III, gender violence, programmes such as deafness, cardiovascular, strokeand diabetes, organ transplant, programme on elderly, National and International Agencieshave been added. After the National Rural Health Mission was launched in 2005, there havebeen significant changes in government approach. Public health is a dynamic process andso is its information. That is why in a span of 8-9 years the author is continuously updatingand has released 7

th edition. This book is important for all professionals, experts, and

officials who are working in the field of public health. This is also useful for students preparingfor civil service examination, PG medical entrance examinations, PG and UG students forcommunity medicine, community nursing, community pharmacy, dentistry, social work, etc.As far as cost and printing of the book is concerned it is of good quality with best economicalprice.

Dr. Suman BansaliAssociate Professor,Department of Community Medicine,Dr. SN Medical College,Jodhpur, Rajasthan

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Rehabilitation needs for olderadults with stroke living athome: perceptions of fourpopulations

Claude Vincent, Isabelle Deaudelin, LineRobichaud , Jacqueline Rousseau, ChantalViscogliosi, Lise R Talbot and JohanneDesrosiers for other members of the BRADgroup

BMC Geriatrics 2007, 7:20doi:10.1186/1471-2318-7-20

Background: Many people who have suffered astroke require rehabilitation to help them resume theirprevious activities and roles in their own environment,but only some of them receive inpatient or evenoutpatient rehabilitation services. Partial and unmetrehabilitation needs may ultimately lead to a loss offunctional autonomy, which increases utilization ofhealth services, number of hospitalizations and earlyinstitutionalization, leading to a significant psychologicaland financial burden on the patients, their families andthe health care system. The aim of this study wasto explore partially met and unmet rehabilitation needsof older adults who had suffered a stroke and who livein the community. The emphasis was put on needsthat act as obstacles to social participation in termsof personal factors, environmental factors and lifehabits, from the point of view of four target populations.

Methods: Using the focus group technique, wemet four types of experts living in three geographicareas of the province of Québec (Canada): older peoplewith stroke, caregivers, health professionals and healthcare managers, for a total of 12 groups and 72participants. The audio recordings of the meetings weretranscribed and NVivo software was used to managethe data. The process of reducing, categorizing andanalyzing the data was conducted using themes fromthe Disability Creation Process model.

Results: Rehabilitation needs persist for ninecapabilities (e.g. related to behaviour or motor activities),nine factors related to the environment (e.g. type ofteaching, adaptation and rehabilitation) and 11 lifehabits (e.g. nutrition, interpersonal relationships). Thecaregivers and health professionals identified moreunmet needs and insisted on an individualizedrehabilitation. Older people with stroke and the healthcare managers had a more global view of rehabilitationneeds and emphasized the availability of resources.

Conclusion: Better knowledge of partially met or

Journal Scan

unmet rehabilitation needs expressed by the differenttypes of people involved should lead to increasedattention being paid to education for caregivers,orientation of caregivers towards resources in thecommunity, and follow-up of patients’ needs in termsof adjustment and rehabilitation, whether for improvingtheir skills or for carrying out their activities of dailyliving.

Discomfort and agitation in olderadults with dementia

Isabelle Chantale Pelletier, Philippe Landreville


Background: A majority of patients with dementiapresent behavioral and psychological symptoms, suchas agitation, which may increase their suffering, bedifficult to manage by caregivers, and precipitateinstitutionalization. Although internal factors, such asdiscomfort, may be associated with agitation in patientswith dementia, little research has examined thisquestion. The goal of this study is to document therelationship between discomfort and agitation (includingagitation subtypes) in older adults suffering fromdementia.

Methods: This correlational study used a cross-sectional design. Registered nurses (RNs) provideddata on forty-nine residents from three long-termfacilities. Discomfort, agitation, level of disability inperforming activities of daily living (ADL), and severityof dementia were measured by RNs who were wellacquainted with the residents, using the DiscomfortScale for patients with Dementia of the Alzheimer Type,the Cohen-Mansfield Agitation Inventory, the ADLsubscale of the Functional Autonomy MeasurementSystem, and the Functional Assessment Staging,respectively. RNs were given two weeks to completeand return all scales (i.e., the Cohen-Mansfield AgitationInventory was completed at the end of the two weeksand all other scales were answered during this period).Other descriptive variables were obtained from theresidents’ medical file or care plan.

Results: Hierarchical multiple regression analysescontrolling for residents’ characteristics (sex, severityof dementia, and disability) show that discomfortexplains a significant share of the variance in overallagitation (28%, p < 0.001), non aggressive physicalbehavior (18%, p < 0.01) and verbally agitated behavior(30%, p < 0.001). No significant relationship is observedbetween discomfort and aggressive behavior but thepower to detect this specific relationship was low .

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Conclusions: Our findings provide further evidenceof the association between discomfort and agitation inpersons with dementia and reveal that this associationis particularly strong for verbally agitated behavior andnon aggressive physical behavior.

The history of falls and theassociation of the timed up andgo test to falls and near-falls inolder adults with hiposteoarthritis

Catherine M Arnold, Robert A Faulkner


Background: Falling accounts for a significantnumber of hospital and long-term care admissions inolder adults. Many adults with the combination ofadvancing age and functional decline associated withlower extremity osteoarthritis (OA), are at an evengreater risk. The purpose of this study was to describefall and near-fall history, location, circumstances andinjuries from falls in a community-dwelling populationof adults over aged 65 with hip OA and to determinethe ability of the timed up and go test (TUG) to classifyfallers and near-fallers.

Method: A retrospective observational study of106 older men and women with hip pain for six monthsor longer, meeting a clinical criteria for the presenceof hip OA at one or both hips. An interview for fall andnear-fall history and administration of the TUG wereadministered on one occasion.

Results: Forty-five percent of the sample had atleast one fall in the past year, seventy-seven percentreported occasional or frequent near-falls. The majorityof falls occurred during ambulation and ascending ordescending steps. Forty percent experienced an injuryfrom the fall. The TUG was not associated with historyof falls, but was associated with near-falls. Higher TUGscores occurred for those who were older, less mobile,and with greater number of co-morbidities.

Conclusion: A high percentage of older adults withhip OA experience falls and near-falls which may beattributed to gait impairments related to hip OA. TheTUG could be a useful screening instrument to predictthose who have frequent near-falls, and thus might beuseful in predicting risk of future falls in this population.

Prevention of fall incidents inpatients with a high risk offalling: design of a randomised

controlled trial with aneconomic evaluation of theeffect of multidisciplinarytransmural care

Geeske Mee Peeters, Oscar J de Vries, PetraJM Elders, Saskia MF Pluijm, Lex M Bouterand Paul Lips


Background: Annually, about 30% of the personsof 65 years and older falls at least once and 15% fallsat least twice. Falls often result in serious injuries, suchas fractures. Therefore, the prevention of accidental fallsis necessary. The aim is to describe the design of astudy that evaluates the efficacy and cost-effectivenessof a multidisciplinary assessment and treatment ofmultiple fall risk factors in independently living olderpersons with a high risk of falling.

Methods/Design: The study is designed as arandomised controlled trial (RCT) with an economicevaluation. Independently living persons of 65 years andolder who recently experienced a fall are interviewedin their homes and screened for risk of recurrent fallingusing a validated fall risk profile. Persons at low riskof recurrent falling are excluded from the RCT. Personswho have a high risk of recurrent falling are blindlyrandomised into an intervention (n = 100) or usual care(n = 100) group. The intervention consists of amultidisciplinary assessment and treatment ofmultifactorial fall risk factors. The transmuralmultidisciplinary appraoch entails close cooperationbetween geriatrician, primary care physician, physicaltherapist and occupational therapist and can beextended with other specialists if relevant. A fallcalendar is used to record falls during one year of follow-up. Primary outcomes are time to first and second falls.Three, six and twelve months after the home visit,questionnaires for economic evaluation are completed.After one year, during a second home visit, thesecondary outcome measures are reassessed and theadherence to the interventions is evaluated. Data willbe analysed according to the intention-to-treat principleand also an on-treatment analysis will be performed.

Discussion: Strengths of this study are theselection of persons at high risk of recurrent fallingfollowed by a multidisciplinary intervention, its transmuralcharacter and the evaluation of adherence. If proveneffective, implementation of our multidisciplinaryassessment followed by treatment of fall risk factorswill reduce the incidence of falls.

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The Newcastle 85+ study:biological, clinical andpsychosocial factors associatedwith healthy ageing: studyprotocol

Joanna Collerton, Karen Barrass, John Bond,Martin Eccles, Carol Jagger, Oliver James,Carmen Martin-Ruiz, Louise Robinson, Thomasvon Zglinicki and Tom Kirkwood


Background: The UK, like other developedcountries, is experiencing a marked change in the agestructure of its population characterised by increasinglife expectancy and continuing growth in the olderfraction of the population. There is remarkably little up-to-date information about the health of the oldest old(over 85 years), demographically the fastest growingsection of the population. There is a need, from botha policy and scientific perspective, to describe in detailthe health status of this population and the factors thatinfluence individual health trajectories. For a very largeproportion of medical conditions, age is the singlelargest risk factor. Gaining new knowledge about whyaged cells and tissues are more vulnerable to pathologyis likely to catalyse radical new insights and opportunitiesto intervene. The aims of the Newcastle 85+ Study areto expose the spectrum of health within an inceptioncohort of 800 85 year-olds; to examine health trajectoriesand outcomes as the cohort ages and their associationswith underlying biological, medical and social factors;and to advance understanding of the biological natureof ageing.

Methods: A cohort of 800 85 year olds fromNewcastle and North Tyneside will be recruited atbaseline and followed until the last participant has died.Eligible individuals will be all those who turn 85 duringthe year 2006 (i.e. born in 1921) and who are registeredwith a Newcastle or North Tyneside general practice.Participants will be visited in their current residence(own home or institution) by a research nurse atbaseline, 18 months and 36 months. The assessmentprotocol entails a detailed multi-dimensional healthassessment together with review of general practicemedical records. Participants will be flagged with theNHS Central Register to provide details of the date andcause of death.

Discussion: The Newcastle 85+ Study will addresskey questions about health and health-maintenance inthe 85+ population, with a particular focus on quantitativeassessment of factors underlying variability in health,and on the relationships between health, nutrition and

biological markers of the fundamental processes ofageing.

Oral health service utilization byelderly beneficiaries of theMexican Institute of SocialSecurity in Mexico city

Sergio Sanchez-Garcia, Javier de la Fuente-Hernandez, Teresa Juarez-Cedillo, JoseManuel Ortega-Mendoza, Hortensia Reyes-Morales, Fortino Solorzano-Santos andCarmen Garcia-Pena

BMC Health Services Research 2007, 7:211doi:10.1186/1472-6963-7-211

Background: The aging population poses achallenge to Mexican health services. The aim of thisstudy is to describe recent oral health servicesutilization and its association with socio-demographiccharacteristics and co-morbidity in Mexican SocialSecurity beneficiaries 60 years and older.

Methods: A sample of 700 individuals aged 60+years was randomly chosen from the databases of theMexican Institute of Social Security (IMSS). Theseparticipants resided in the southwest of Mexico Cityand made up the final sample of a cohort study foridentifying risk factors for root caries in elderly patients.Sociodemographic variables, presence of cognitivedecline, depression, morbidity, medication consumption,and utilization of as well as reasons for seeking oralhealth services within the past 12 months werecollected through a questionnaire. Clinical oralassessments were carried out to determine coronal androot caries experience.

Results: The sample consisted of 698 individualsaged 71.6 years on average, of whom 68.3% werewomen. 374 participants (53.6%) had made use of oralhealth services within the past 12 months. 81% of thosewho used oral health services sought private medicalcare, 12.8% sought social security services, and 6.2%public health services. 99.7% had experienced coronalcaries and 44.0% root caries. Female sex (OR=2.0),6 years’ schooling or less (OR=1.4), and cariesexperience in more than 22 teeth (OR=0.6) are factorsassociated with the utilization of these services.

Conclusions: About half the elderly beneficiariesof social security have made use of oral health serviceswithin the past 12 months, and many of them haveto use private services. Being a woman, having littleschooling, and low caries experience are factorsassociated with the use of these services.

Instructions for AuthorsJournal of the Indian Academy of Geriatrics is an

official publication of the Indian Academy of Geriatrics. Thispeer-reviewed Journal would be published quarterly (March,June, September and December). It publishes regulararticles-original clinical studies and experimentalinvestigations, review of basic and clinical topics, briefcommunications, case reports concerning all aspects ofGeriatrics.

General information

Regular Articles are full length papers that addressresearch questions with exhaustive study design andmethodology. The entire manuscript including abstract andreferences should not exceed 15 typed pages in doublespace and should not contain more than 30 references.

Brief Communications should contain not more than2000 words (including abstract, figures, tables andreferences) describing important new observations inGeriatrics.

Review of basic and clinical topics of interest to thereadership will be solicited by the editors. The length ofreview articles should not exceed fifteen typed pages.

Case reports should be limited to 1200 words,should not have more than 4 authors and should notcontain over 2 illustrations and 10 references.

Letters to the editor containing interestingobservations and comments on the articles published inthe journal are welcome for publication. Due care shouldbe taken in the formation of the letter to avoid anymisunderstanding. The replies to such letters will also bepublished as and when received from the authors. Theletter and the reply should not exceed 300 words andshould not contain more than 5 references.

The manuscript would be forwarded to an associateeditor and two reviewers. Manuscripts that are outside therange of interest of Journal of The Indian Academy ofGeriatrics readership or that fail to satisfy the technicalrequirements would be rejected and returned to authorswithout further review. Only glossy prints and photographsof rejected manuscripts would be returned to reduceexpenditure on mailing. The rejected manuscript would bedestroyed. Manuscript returned to authors for modificationshould be returned to editorial office as early as possiblebut not later than 3 months, after which the article wouldbe filed and not considered for publication. The editorialboard reserves the right to assess suitability of the language,modify the letter and text, improve the photographs and

illustrations to enhance clarity of expression andpresentation without affecting the message and meaningbeing conveyed by the article.

Manuscript preparation

Submit an original manuscript and three photocopies,typed double spaced in letter quality print on one side onlyof standard (8 ½ x 11 inch) white bond paper. Manuscriptsshould be organized as follows; title page, abstract,introduction, methods, results, discussion,acknowledgements, reference, tables and figure legends.Cite references and figures by numbers in the text.

All weights and measures must be given in metricunits. Avoid use of full stops in the middle of abbreviations(ECG, not E.C.G.).Serial number of each reference shouldbe superscripted and not written in parenthesis. It isadvised to follow the uniform requirements for manuscriptsubmission in Biomedical journals i.e as mentioned inBMJ 1988; 296

Title page

The title should be brief and comprehensive,preferably less than fifteen words with the first letter of eachword typed in capitals. The name of the authors (initialsfollowed by surnames) should be written in continuationfollowed by the name of the department and the Institutionwhere the study was carried out. A footnote may be addedto indicate address for correspondence and e-mail address.All authorship must fulfill Vancouver agreement (BMJ 1991;302)

Abstract

State the problem considered, methods, results andconclusions in less than 250 words, and key words. Theabstract should consist of four paragraphs, labeledBackground, Methods, Result and Conclusions.

Tables

Type double-spaced on separate sheets of standardsized white bond paper. Each table should have a title andbe numbered in the order of appearance in the text. Itshould be brief and self explanatory. Abbreviations, if used,should be explained in the footnote. The data presentedshould not be duplicated in the text and figures. Usesuperscript letters to indicate footnotes typed at the bottomof the table.

Figures

Four complete sets of glossy photographs of allfigures including graphs, black and white and color

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photographs must be submitted. The use of colorillustrations is encouraged, but authors should contact theeditor prior to their preparation for advice and assistance.All figures should be clearly labeled on the back with a leadpencil and an arrow indicating the top edge of the figure.Photomicrograph should be sized to fit one column (8cm)or two columns (17cm); the maximum plate size is 17 x22 cm.

Graphs must be of professional quality. Computergenerated graphs should be of laser quality. High contrastprints of roentgenographic photographs and electronmicrographs are essential. Clear photocopies of the figuresshould be included with the original and each copy of themanuscript.

References

References should be typed at the end of the text indouble space following the Vancouver style and numberedin the order of appearance in the text, with only onereference to a number. Citation of unpublished observationsor personal communications (include separatelypermission to quote from appropriate individual) shouldbe placed in the text in parenthesis. Reference number inthe text should be typed as superscript and not in thebrackets. e.g. Dyslipidemia in elderly10.It is desired tofollow the style and pattern for abbreviations as given inIndex Medicus.

Journal article

Luke RG, Jones P and Diethelm AG. Hypertensionin elderly. Am J Med1982; 75; 88-95

Abstract

Yoo KH, Norwood VF, Chevalier RL. Regulation ofAging (Abstract).Nature1995; 65:82-91

Chapters in Book

John T Potts: Disorders of the parathyroid gland;Harrison’s Principles of Internal Medicine,15 edn.,Braunwald, Fauci, Kasper, Hauser,et al (eds),McGrawHill,2001,p2224-6

General instructions

Use generic names of drugs. Do not use abbreviationsin the title. Define unusual abbreviations with the first usein the body of the manuscript. Text footnotes should betyped on a separate page. For references the names ofall authors should be mentioned instead of using et al.The abbreviations used for name of a particular journalshould be standard.

Manuscript on Compact Disks

Authors must submit compact disk of the final versionof their manuscripts along with the printout of the revised

manuscript in Microsoft word. Identify the diskette byproviding journal name, manuscript number, senior author’sname, manuscript title, name of computer file, type ofhardware, operating system and version number, andsoftware program and version number. The journal doesnot assume responsibility for errors in conversion ofcustomized software, new software, and special characters.Mathematics and tabular material will be processed in thetraditional manner. PDF format submission is not desired.The photographs should be submitted in .jpg file format.

Manuscripts submitted should not have beenpublished earlier or be under simultaneousconsideration for publication by any other journal. Astatement to this effect (Authors’ Declaration) signed by theauthors should accompany each manuscript. Violationmay lead to a published retraction of the article by theJournal and other actions as deemed necessary by theeditor. Accepted manuscripts become the permanentproperty of the Journal and may not be reproduced, inwhole or in part, without the written permission of the editor.

Studies involving intervention in human subjects oranimals should have received the approval of the institutionalethics committee. A statement to this effect must beincluded in the manuscript text. If the institution has noformal ethics committee, a statement signed by the authorsthat the terms of the Helsinki Agreement have beenadhered to will be necessary.

We encourage authors to submit manuscripts inelectronic version, as a Word document to e-mail address;accompanying Figures should be as .jpg file attachments.Printed copies need not be submitted then. If the articleis accepted, they will be required to submit Figures as hardcopies or in high-resolution format. A printed copy of thesigned Authors’ Declaration must be submitted if the articleis accepted for publication.

Manuscript for publication in Journal of The IndianAcademy of Geriatrics should be sent to Dr. Arvind Mathur,Editor, Journal of The Indian Academy of Geriatrics,Room No. 9, Department of Medicine, Mathura DasMathur Hospital, Shastri Nagar, Jodhpur 342003Rajasthan, India, Tel. : 0291-2620999, Fax : 0291-2441678;Email - journal_geriatrics@ yahoo.com. The editor andthe publisher disclaim any responsibility or liability for thestatements made and opinion expressed by authors.

All manuscripts submitted to this Journal must beaccompanied by the declaration signed by all authors,before they can be processed editorially. If it cannot besigned by any authors, the principal or correspondingauthor can take responsibility and sign on behalf. Thisdocument can be photocopied as required for submission.

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CHECKLIST FOR THE MANUSCRIPT1. Letter of Submission.

2. Transmittal letter signed by all Authors.

3. Include three original typed manuscript and three photocopies if submitted by post.

4. Title Page:

• Title page of Manuscripts.

• Full name (s) of and affiliation of author(s), Institution(s) and city (ies) from which work originated.

• Name, Address, telephone, fax numbers and e-mail address of corresponding author.

• Running title ( Less than 50 letters)

• Number of pages, number of figures and number of tables.

5. Abstract

6. Article proper ( double spaced )

7. Acknowledgements ( separate sheet )

8. Reference ( double spaced, separate sheet )

9. Tables ( separate sheet )

10. Figures/ Photographs on separate sheet.

11. Permission to reproduce published material.

12. Send one set of glossy print figures accompanied with three photcopies.

13. Authors’ Declaration

14. Designate a corresponding author and provide a telephone number, fax number, email and mailing address.

AUTHORS’ DECLARATION

We, the authors of the article entitled “__________________________________” submitted for consideration forpublication in Journal of the Indian Academy of Geriatrics, declare that:

1. We have seen and approved the text of the manuscript, and take responsibility for its contents as its authors;we consent to its publication in Journal of the Indian Academy of Geriatrics if it is accepted for publicationby the Journal.

2. We state that all clinical investigation described in the manuscripts been under taken in accordance withthe guidelines proposed in the Declaration of Helsinki.

3. This work in the submitted or an essentially similar version has not been published elsewhere, is not undersimultaneous consideration for publication elsewhere, and will not be submitted for publication elsewherewhile under consideration by Journal of the Indian Academy of Geriatrics. This does not duplicate any datapreviously reported. If any part of the material submitted has been previously published, except in the formof an Abstract, we enclose copies of the previous publication.

4. In consideration of Journal of the Indian Academy of Geriatrics taking action in editing and reviewing oursubmission, we hereby transfer, assign or otherwise convey all copyright ownership to the Indian Academyof Geriatrics in the event that this article is published in Journal of the Indian Academy of Geriatrics.

Authors’ names and Signatures ______________________________________________

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THE INDIAN ACADEMY OF GERIATRICS (IAG)

MEMBERSHIP APPLICATION FORM

Name _____________________________________________Date of Birth_____________________Sex__________

Educational Qualification ___________________________________________________________________________

University ________________________________________________________________________________________

Present position & Office Address __________________________________________________________________

________________________________________________________________________________________

Telephone No. _____________________________________________________________________________

Email ____________________________________________________________________________________

Fax ______________________________________________________________________________________

Type of Membership - Life member Regular / Life Member Associate Life Member Fees Rs. 1000/- by D.D./Cheque(Out Station Cheques, add Rs. 50/- extra as bank charges) drawn in favour of Secretary, The Indian Academyof Geriatrics.

I agree to become a member and if I admitted to abide by the rules and regulation of the association.

Signature of the applicant

Mail to : The Secretary, THE INDIAN ACADEMY OF GERIATRICS Dr.Shanthi G.S., AB-77,1st Street, Anna Nagar, Chennai, Tamilnadu,600040-India.

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The Indian Academics of Geriatrics was formed on 26th April 2002 atChennai and has been registered under the Indian Society Act. TheAcademy has been formed to associate Physicians practicing thescience and art of Geriatrics.

The Academy has the following objectives:

• To conduct meaningful research in geriatrics and to assist inproviding adequate technical knowledge in geriatrics

• To organize scientific programs, conferences, workshops andtraining programs in geriatrics

• To print and publish a journal, and other literature relating to thescience of geriatrics.

• To encourage scientific research and experimental work ongeriatrics & gerontology.

RULES AND REGULATIONS REGARDING ADMISSIONLife Member - RegularAny person with post graduate degree such as MD, or DNB in Geriatrics / Internal Medicine with training orexperience in Geriatrics, from any institution (or) University, recognised by the MCI or by the governing body ofthe Association, shall be enrolled. Any person qualified to be Life member regular, could be enrolled after payingone time subscription fees, that is non refundable.

Life Member - AssociateAny person having basic degree recognised by the MCI, who is not eligible for life membership regular and personswith post graduate qualification in allied non medical discipline like Psychology, Sociology and Social work shallbe enrolled as Life Member associate.Associate members have no voting right nor the right to propose, second or contest for any office of the ExecutiveCommittee.

Documents

JOURNAL OF THE INDIAN ACADEMY OF GERIATRICS n Info/Articles/JOURNAL OF... · Journal of The Indian Academy of Geriatrics, Vol. 3, No. 4, December, 2007 and emergency healthcare for